"Insurance Companies Often Fail to Properly Pay Cancer Insurance Claims"

Analysis of Cancer Insurance-Related Consumer Complaints Received by the Consumer Agency from 2018 to Last Year

Status of Damage Relief Applications by Cancer Type.

[Asia Economy Reporter Lim Chun-han] Despite being diagnosed with cancer, many cases have been reported where insurance companies refuse to pay cancer insurance benefits based on exemption clauses in the policy that were not explained or after conducting their own medical consultations.

On the 6th, the Korea Consumer Agency announced that an analysis of 451 cancer insurance-related damage relief applications received from 2018 to last year showed that 88.2% of the cases were related to insurance benefit payments. The representative cases involved denial or underpayment of benefits.

By cancer type, damage relief applications related to colorectal cancer and thyroid cancer accounted for 27.3% and 19.5% of the total cases, respectively. They were followed by breast cancer (13.3%) and bladder cancer (5.1%). In particular, among colorectal cancers, cases related to neuroendocrine tumors accounted for 71.5%, and for thyroid cancer, thyroid metastatic cancer made up 86.4%, representing the majority.

Earlier, in 2018, the Supreme Court ruled in a dispute between consumers and insurance companies regarding neuroendocrine tumor-related cancer insurance benefits that, according to the "principle of disadvantage to the drafter," insurance benefits for general cancer, not borderline tumors, should be paid. However, the Korea Consumer Agency pointed out that insurance companies typically pay only 10?30% of the general cancer insurance benefits for borderline tumors, which are intermediate between benign tumors (cysts) and malignant tumors, through their own medical consultations.

The Korea Consumer Agency emphasized, "Recently, the World Health Organization (WHO) classified neuroendocrine tumors as malignant tumors in the 5th edition of the Digestive System Tumor Classification, and the 8th edition of the Korean Standard Classification of Diseases and Causes of Death (KCD-8) was revised accordingly. Therefore, insurance companies should pay general cancer insurance benefits, not borderline tumor benefits."

Unlike thyroid cancer, which is classified as a minor cancer due to its good prognosis, thyroid metastatic cancer, where cancer cells from the thyroid spread to lymph nodes or other organs, is classified as general cancer. However, insurance companies have caused disputes by paying only 10?30% of the general cancer insurance benefits based on an exemption clause in the policy stating, "In the case of thyroid metastatic cancer, it is classified according to thyroid cancer."

According to a 2015 Supreme Court precedent, exemption clauses for insurance benefits are important contents of the insurance contract, so if there was no separate explanation at the time of contract conclusion, the insurance company cannot use the clause as a basis for denying benefits. Accordingly, the Korea Consumer Agency has requested insurance companies to pay general cancer insurance benefits for thyroid metastatic cancer.

The Korea Consumer Agency urged consumers to carefully check the restrictions on insurance benefit payments when subscribing to insurance and to claim insurance benefits before the expiration of the claim period (3 years) to prevent consumer damage.

This content was produced with the assistance of AI translation services.