"Why Am I Not Getting My Cataract Insurance Payout?" Angry Policyholders Consider Class Action Lawsuit

Conflicts between insurance companies and policyholders over cataracts in indemnity health insurance (실손보험) are significantly increasing. As indemnity insurance deficits worsened due to excessive cataract treatments, insurers have tightened the review of cataract insurance claims, leading to growing dissatisfaction among policyholders who did not receive payments, escalating to class-action lawsuits.

According to the insurance industry on the 23rd, attorney Choi Hye-won (Law Firm Sanji), who specializes in insurance cases, recently posted a notice online for a "Cataract Surgery Insurance Claim Class Action" and is recruiting plaintiffs who underwent cataract surgery but did not receive indemnity insurance payments.

The eligibility criteria are indemnity insurance policies subscribed before 2016, which are 1st or 2nd generation indemnity insurance, where insurance payments were denied despite medical records indicating hospitalization for 6 hours or more.

Attorney Choi explained, "Whether cataract surgery is for treatment purposes or vision correction is important. For insurance policies subscribed before 2016, multifocal lens implantation due to cataract surgery can be considered treatment, so there is a possibility of winning the lawsuit."

Cataracts refer to a condition where the lens becomes cloudy, preventing light from passing properly, causing the vision to appear foggy as if covered by mist. The cloudiness of the lens is classified into stages 1 to 6, and surgery is generally considered from stage 3 onwards.

The problem is that insurers have recently strengthened the review of indemnity insurance payments related to cataract surgery, resulting in an increase in people who did not receive indemnity insurance payments after cataract surgery.

Until last year, most insurers paid indemnity insurance claims after surgery regardless of the cataract stage, but from this year, they have intensified medical consultations, and if the cloudiness is low or it is judged not to be for treatment purposes, cases of payment refusal have increased.

Insurers explained that they strengthened the review because indemnity insurance payments for cataract surgery more than doubled compared to the previous year, worsening the indemnity insurance deficit.

In fact, the proportion of cataract surgery-related indemnity payments among total indemnity insurance payments was 6.8% in 2020, 9.1% in 2021, and surged to around 13% this year. Financial authorities and the insurance industry have identified that the abnormal surge in cataract surgeries is due to excessive treatments at some ophthalmology hospitals.

However, insurance policyholders are strongly opposing this. They argue that insurers are refusing to pay claims in violation of the policy terms. This year, complaints related to non-payment of cataract insurance claims submitted to the Presidential Transition Committee's public proposals exceeded 8,000 cases, ranking first overall, indicating that class-action lawsuits were anticipated.

They pointed out that if excessive diagnosis is the problem, measures should be taken to correct the hospitals, but it is problematic to refuse insurance payments by blaming the insurance policyholders as if they are at fault.

An insurance industry official said, "Due to the severe indemnity insurance deficit caused by excessive cataract treatments, strengthening the review was inevitable," adding, "As conflicts are growing, it is necessary to carefully check the possibility of indemnity insurance payment before undergoing surgery."

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