Increasing Insurance Company Medical Consultations... Concerns About Not Receiving My Insurance Payment

[Asia Economy Reporter Changhwan Lee] As the number of medical consultations by insurance companies increases, it has been found that the possibility of insurance subscribers not receiving their insurance payments properly is also rising.

Insurance companies are increasing medical consultations to improve the deficit of indemnity health insurance (실손보험), but this may reduce insurance payments, raising concerns about disputes with insurance consumers.

According to the Financial Consumers Federation (금소연) on the 9th, last year the number of medical consultations by domestic non-life insurance companies reached 42,274, the highest ever. Insurance companies seek medical advice from specialists affiliated with medical institutions when it is difficult to determine insurance payment decisions.

The increase in medical consultations by insurance companies is closely related to the indemnity insurance deficit. According to the Financial Supervisory Service, last year the total deficit of indemnity insurance by domestic insurers was 2.86 trillion KRW, the largest ever. It has been in deficit for six consecutive years since 2016.

It is analyzed that the indemnity insurance deficit is increasing due to overmedical treatment. The Financial Supervisory Service explained that due to the product structure of past products with low self-pay ratios (0% self-pay ratio for first-generation products), it is difficult to respond efficiently to overmedical use, which is causing the indemnity insurance deficit to grow. Frequent overmedical treatment items include manual therapy, adjustable intraocular lenses (multifocal lenses for cataract surgery), and extracorporeal shock wave therapy.

As overmedical treatment worsens and the indemnity insurance deficit continues, insurance companies are strengthening medical consultations to prevent excessive insurance payments. The problem is that the increase in medical consultations may cause harm to innocent victims.

There are concerns that cases occur where insured persons who received appropriate treatment and should rightfully receive insurance payments suffer damages because insurance companies decide to deny payments through medical consultations. The industry estimates that nearly half of the cases where insurance companies conduct medical consultations result in delayed payments or lawsuits.

Recently, the Financial Supervisory Service’s revision of the model guidelines for insurance fraud prevention to prevent insurance payment leakage has also raised concerns about an increase in unnecessary medical consultations. The Financial Supervisory Service is allowing stronger reviews such as medical consultations for suspected insurance fraud cases to prevent insurance payment leakage.

A representative from the Financial Consumers Federation stated, "If there is a problem with insurance payment leakage due to overdiagnosis and overtreatment, measures should be taken to correct doctors and hospitals, but the Financial Supervisory Service and insurance companies are wrongly delaying insurance payments by blaming the insurance policyholders as if they are the problem."

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