[Getting Insurance Savvy] Marginal Resection Surgery Said Not to Be Surgery... "It Is Surgery"

Controversy Over
Wound Suturing Including Marginal Resection
Financial Supervisory Service Subcommittee: "Pay Surgery Insurance Benefits"

[Image source=Yonhap News]

[Asia Economy Reporter Oh Hyung-gil] A first ruling has been made that treatment involving suturing after removing severely contaminated or necrotic tissue from a wounded area qualifies as surgery, and thus surgical insurance benefits must be paid.

This is a new judgment regarding wound suturing, including marginal excision, which had not been covered by insurance until now. In the past, insurance companies denied payment, claiming that marginal excision?which involves cutting away contaminated tissue and suturing the wound?did not qualify as surgery.

The Financial Supervisory Service’s Dispute Mediation Committee recently recommended that Hanwha General Insurance pay injury surgery benefits, stating that wound suturing including marginal excision falls under the definition of surgery according to the insurance policy.

Contractor A sustained an open wound of 2.5 to 5 cm on the wrist while sawing in late April 2019 and received wound suturing treatment including marginal excision at Hospital B’s emergency room.

A claimed 1 million KRW in insurance benefits through the surgical expense rider of the subscribed insurance, but the insurer refused payment, arguing that it did not meet the definition of surgery.

The policy defines surgery as "the use of medical instruments to perform operations such as cutting or excision on the living body for direct treatment purposes." However, it excludes "new surgical techniques recognized for safety and therapeutic effect by the New Medical Technology Evaluation Committee, as well as procedures such as aspiration, puncture, and nerve blocks."

Accordingly, the insurer viewed wound suturing as a procedure or medical treatment and denied the insurance payment.

However, the Dispute Mediation Committee’s decision differed. It regarded wound suturing as a surgical process requiring medical expertise, falling under the policy’s definition of surgery involving operations such as cutting or excision. It also ruled that since it is not similar to aspiration, puncture, or nerve block procedures, it is not excluded from the meaning of surgery.

The committee also presented the detailed medical expense statement issued by the treating hospital to A, which listed marginal excision (disease code SC022 from the Health Insurance Review & Assessment Service) under the "surgery fee" category.

Furthermore, court precedents cited by the committee interpreted the definition of surgery in insurance policies broadly.

The courts have ruled that radiofrequency thermal ablation for thyroid nodules (Seoul Central District Court, 2014) and laser treatment for congenital ectopic Mongolian spots (Seoul High Court, 2019) meet the definition of surgery under insurance policies. They recognized that surgery includes not only direct cutting or excision but also removal of the target tissue using radiofrequency or laser.

This Dispute Mediation Committee ruling is expected to have a significant impact on future surgical insurance benefit payments by insurers. Most insurers have used similar definitions of surgery in their policies. Some insurers have denied payments on a case-by-case basis depending on the extent of treatment due to ambiguous surgical expense clauses.

A financial authority official stated, "Marginal excision involves cutting away contaminated tissue. Therefore, if wound suturing includes marginal excision, it is considered surgery. However, wound suturing or muscle suturing that does not include marginal excision is not subject to insurance payment."

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