Supreme Court: "Cataract Surgery Cannot Be Uniformly Recognized as Inpatient Treatment"

Existing Indemnity Insurance Treated 'Cataract Surgery = Hospitalization'
Supreme Court Ruling Expected to Impact Insurance Industry

[Asia Economy Reporter Kim Young-won] A ruling has been made that cataract surgery should not be uniformly recognized as inpatient treatment. Cataract surgery has so far been processed as inpatient treatment in the handling of indemnity insurance claims.

According to the insurance industry on the 19th, the Civil Division 2 of the Supreme Court on the 16th dismissed the appeal without oral argument, thereby confirming the lower court's ruling in favor of the plaintiff in a lawsuit filed by Insurance Company A against indemnity insurance policyholder Mr. B, who underwent cataract surgery, seeking a declaration of non-existence of debt. Dismissal without oral argument is a system where an appeal is dismissed without substantive review if there is no special reason such as a serious violation of law in the lower court's decision.

Mr. B, who was diagnosed with senile cataract and underwent surgery at an ophthalmology clinic in Seoul in August 2019, claimed insurance on the grounds that the surgery he received qualified as inpatient treatment. However, Insurance Company A regarded it as outpatient treatment and filed a civil lawsuit against Mr. B.

Mr. B had previously subscribed to insurance with Insurance Company A covering disease outpatient indemnity medical expenses (outpatient), disease outpatient indemnity medical expenses (prescription), and injury/disease inpatient indemnity medical expenses. The insurance applies a coverage limit of 50 million KRW for inpatient medical expenses, but only 250,000 KRW for outpatient medical expenses (outpatient).

The first trial court ruled that Mr. B's treatment qualified as inpatient treatment, but the second trial court ruled in favor of the insurance company, stating that it was outpatient treatment, not inpatient treatment. The Supreme Court confirmed this second trial ruling.

The court judged that considering the definitions in the insurance policy, Supreme Court precedents, and the Ministry of Health and Welfare notices, it is difficult to see that the cataract surgery Mr. B received qualifies as inpatient treatment. The court held that to qualify as inpatient treatment, the patient must stay in the inpatient room for at least six hours or receive treatment/surgery and be continuously observed for six hours. In Mr. B's case, the cataract surgery preparation and completion took about two hours.

Furthermore, the court ruled that the mere issuance of admission and discharge certificates does not constitute inpatient treatment. The ophthalmology clinic where Mr. B underwent surgery did not operate inpatient rooms or beds according to data from the Health Insurance Review & Assessment Service.

Meanwhile, cataracts have been cited as a major cause of indemnity insurance deficits along with manual therapy due to many cases of false or excessive claims. According to data from the Life Insurance & Non-Life Insurance Association, indemnity insurance payments made by life and non-life insurers for cataract surgery reached a provisional record high of 457 billion KRW in the first quarter of this year.

Since cataract surgery has been uniformly recognized as inpatient treatment in the existing indemnity insurance payment process, this ruling is expected to impact the insurance industry.

An insurance industry official said, "Cataract surgery has been uniformly recognized as inpatient treatment, but the judiciary's judgment interprets the current practice of paying indemnity insurance benefits as if it were inpatient treatment without considering individual patient conditions as unreasonable," adding, "In the future, it may become impossible to receive full insurance payments for cataract surgery, and high-cost procedures may face difficulties in indemnity insurance payments."

There are also calls for measures to prevent situations where patients who need inpatient treatment become victims. A financial regulatory official stated, "There are cataract patients who must receive inpatient treatment, and there should be no innocent victims due to this ruling," adding, "How to determine the appropriateness of inpatient treatment will become a new challenge."

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