"Received Non-Covered Treatment but No Reimbursement from Actual Medical Expense Insurance"...Increase in Consumer Complaints

[Asia Economy Reporter Jeon Jinyoung] It has been revealed that insurance companies are strengthening the review of insurance claims for certain non-reimbursable treatments such as cataract surgery and manual therapy, and cases of reducing or denying insurance payments by applying the out-of-pocket maximum system are increasing.

According to the Korea Consumer Agency on the 12th, a total of 206 claims related to non-payment of indemnity for actual medical expense insurance filed with the Consumer Agency over the past four years have been on the rise annually. In 2021, 80 cases were filed, showing an increase of about 400.0% compared to 16 cases in 2018. Among these, claims related to the out-of-pocket maximum system totaled 43 over four years, rising from 2 cases in 2018 to 25 cases last year.

In particular, contracts made before the enactment of the standard terms and conditions for actual medical expense insurance in 2009 did not include any provisions related to the out-of-pocket maximum system under the 'non-compensable matters' clause, yet insurance companies were retroactively applying this to limit insurance payments.

Accordingly, in February, the Consumer Dispute Mediation Committee of the Consumer Agency decided that if there is no explicit provision in the terms and conditions, insurance payments should be made in full regardless of the out-of-pocket maximum system. Supporting private insurance companies with the health insurance funds paid by the public contradicts the purpose of introducing the out-of-pocket maximum system to alleviate household burdens caused by severe and chronic diseases.

Based on this result, the Consumer Agency plans to recommend insurance companies to improve the claim review standards regarding the application of the out-of-pocket maximum system in actual medical expense insurance and to establish measures to prevent consumer damage.

Furthermore, consumers were advised to ▲ consider the possibility of premium increases when subscribing to insurance, ▲ check for exemptions, ▲ obtain objective test results for non-reimbursable treatments when claiming insurance, and ▲ carefully decide whether to consent to medical consultations.

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