'Overstating Hair Loss Treatment for Insurance Claims' Dermatologist Fined for Conspiracy

[Asia Economy Reporter Kim Daehyun] A doctor who was prosecuted for helping hair loss patients inflate their outpatient visits to fraudulently claim insurance payments, known as 'insurance money splitting claims,' enabling patients to covertly recover their out-of-pocket medical expenses from insurance companies, was sentenced to a fine in the first trial.

According to the court on the 1st, Judge Kwon Young-hye of the Seoul Central District Court Criminal Division 25 recently sentenced hospital director A (51, male), who was indicted for violating the Special Act on the Prevention of Insurance Fraud, to a fine of 30 million won.

Previously, A was prosecuted on charges of conspiring to allow 141 hair loss treatment patients insured under medical expense insurance to fraudulently claim insurance payments while operating a dermatology clinic in Gangnam-gu, Seoul, from 2016 to 2020.

When a patient insured under medical expense insurance receives outpatient treatment for a specific disease, the insurance company guarantees the amount obtained by subtracting the deductible amounts per item according to the policy from the sum of the patient's co-payment and non-covered expenses under the National Health Insurance Act. Each insurance product has a coverage limit per 'one outpatient visit' for the patient.

According to the investigation agency, A inflated the number of outpatient visits so that patients could minimize their out-of-pocket expenses for high medical and treatment fees by falsifying detailed medical expense statements and receipts. It was also confirmed that during the patient recruitment process, he explained this method of claiming insurance money to induce high payments. Patients used this method to claim a total of 770 times to various insurance companies, receiving a total of about 110 million won in insurance payments.

Judge Kwon stated, "Such insurance fraud imposes an economic burden on many honest policyholders and causes moral hazard, undermining the reliability of the insurance system, which makes the nature of the crime serious. Even if the benefits from the insurance payments went to the individual patients, the defendant gained economic benefits by recruiting patients who reduced their treatment costs through fraudulent means and receiving corresponding medical fees."

He added, "However, the defendant confessed and showed remorse, and actively cooperated during the investigation. The number of problematic claims was about 2% of the total number of medical visits from 2016 to 2020, so it is difficult to conclude that the defendant systematically engaged in fraudulent operations. The defendant paid the full amount of insurance money, including legitimate medical records processed on the disputed treatment dates, to each insurance company and reached a settlement, and the affected insurance companies do not wish for the defendant’s punishment." Consideration was also given to the fact that A has no prior record exceeding a fine and continues to contribute through donations and volunteer work using his professional medical skills.

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