"Cataract Surgery Done, Why No Reimbursement from Insurance?"... Surge in Complaints to Insurance Companies

[Asia Economy Reporter Changhwan Lee] # Mr. A, a man in his 60s living in Seoul, was diagnosed with cataracts at an ophthalmology clinic at the end of last year and underwent surgery on both eyes earlier this year. Having spent several million won on the surgery, Mr. A filed a claim for reimbursement with insurance company B. However, B denied the payment, stating that Mr. A’s cataracts had not progressed to a stage requiring surgery and requested a third-party medical consultation. They essentially judged the cataract surgery to be an unnecessary overtreatment. Mr. A, who underwent surgery based on his doctor's recommendation, filed a complaint with the Financial Supervisory Service (FSS), questioning why the insurer refused to pay the insurance benefits.

Since the beginning of this year, disputes over insurance payments between insurance consumers and non-life insurance companies have surged. It is interpreted that conflicts are increasing as non-life insurers have tightened their review of claims for indemnity health insurance, particularly due to overtreatment in cataract surgeries.

According to the Financial Supervisory Service and the General Insurance Association, the number of dispute resolution applications received by domestic non-life insurers in the first quarter of this year was 7,850, a 25% increase from 6,258 cases during the same period last year. The number of lawsuits filed amid disputes rose sharply by 50%, from 20 last year to 30 this year.

Complaints have also increased. The total number of complaints received by non-life insurers in the first quarter was 10,727, up 16% from 9,278 in the same period last year. Among these, complaints related to insurance claim payments surged 36%, from 5,915 to 7,958. This is interpreted as policyholders filing complaints due to not receiving compensation or dissatisfaction with the amount paid.

Insurance consumers can file financial complaints with the Financial Supervisory Service if conflicts arise with insurers over claim payments or calculation methods. Upon receiving complaints, the FSS classifies them as either dispute resolution or complaints depending on the severity of the conflict and facilitates agreements between the parties involved.

The increase in conflicts between insurance consumers and insurers in the first quarter is attributed to the rise in insurance fraud and worsening deficits in indemnity insurance, which led insurers to strengthen their claim review processes. In particular, as claims for indemnity insurance related to cataract surgeries surged, conflicts over overtreatment intensified.

According to the insurance industry, indemnity insurance payments for cataract surgeries in the first quarter of this year reached a provisional record high of 457 billion won. The proportion of indemnity insurance payments for cataract surgeries among total indemnity insurance payouts rose sharply from 9.0% at the end of last year to 17.4% in March this year.

Insurers believe that the rapid increase in cataract surgeries is due to overtreatment by some ophthalmology clinics. Some doctors have been recommending expensive cataract surgeries that are not strictly necessary for profit, leading to a surge in indemnity insurance claims.

An insurance industry official explained, "As indemnity insurance claims for cataract surgeries have excessively increased this year, worsening deficits have forced insurers to tighten their claim review processes."

In response to the surge in insurance-related complaints, the FSS launched a 'Dispute Resolution Task Force (TF)' focused on indemnity insurance complaints earlier this month. Anticipating that existing staff would be unable to quickly resolve the influx of complaints, the FSS plans to shorten dispute resolution times by adding about 20 more personnel.

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