Insurance Industry Takes Action Against Cataract Over-Treatment: "Reward for Reporting Insurance Fraud"

[Asia Economy Reporter Changhwan Lee] The insurance industry announced on the 17th that it will actively receive reports related to the recent surge in cataract overtreatment and insurance fraud, and will expand rewards for reports that help investigations.

The Life Insurance Association explained that claims for actual expense insurance payments have surged as broker organizations have spread aggressive marketing, such as some ophthalmology clinics encouraging patients to undergo cataract surgery.

The average monthly payment for cataract-related actual expense insurance claims by the three major life insurance companies was 11.2 billion KRW last year, but surged to 14.9 billion KRW in January this year and 18 billion KRW in February.

The average monthly payment for cataract-related actual expense insurance claims by the ten major non-life insurance companies was 79.2 billion KRW last year, and also increased significantly to 102.2 billion KRW in January and 108.9 billion KRW in February this year.

Among approximately 1,663 ophthalmology clinics nationwide, the average monthly payment for cataract surgery actual expense insurance claims at the top 50 clinics last year increased by 64.4%, from 5.28 billion KRW to 8.68 billion KRW (3-month average) in January this year.

The top 50 clinics for actual expense insurance payments were concentrated in certain areas (such as Gangnam, Seoul), and the cost of non-reimbursable multifocal lens bilateral surgery at these clinics was 14 million KRW, more than twice the typical 6 million KRW surgery cost at general ophthalmology clinics.

The association estimated that some problematic ophthalmology clinics lure patients with actual expense insurance by offering partial refunds of medical fees and excessively charge for non-reimbursable multifocal lenses for vision correction, thereby shifting costs to actual expense insurance payments and making excessive profits.

Such suspected violations are rapidly increasing mainly in ophthalmology clinics in certain areas (such as Gangnam, Seoul). This causes relative deprivation among most honest doctors operating ophthalmology clinics normally and risks misidentifying them as an unethical group, the association emphasized.

It also added that this increases the premium burden on private actual expense insurance subscribers and causes leakage of health insurance finances, ultimately leading to increased insurance premiums for honest citizens.

Accordingly, the Life and Non-Life Insurance Associations, together with the Financial Supervisory Service, announced plans to expand rewards for reports received during the special reporting period (April 18 to May 31) related to ophthalmology clinics and to encourage active reporting.

If investigations proceed on reported problematic ophthalmology clinics during the special reporting period and the reporter provides concrete evidence and witness statements with active cooperation recognized by investigative agencies, fixed rewards ranging from 1 million KRW to a maximum of 30 million KRW will be paid depending on the reporter’s category.

Additionally, if the reported case is forwarded and prosecuted (by the prosecution) as insurance fraud under the Special Act on Prevention of Insurance Fraud, additional rewards will be paid according to the currently operating ‘Insurance Crime Reward Operation Standards.’

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