Medical Opinion Framework for Insurance Disputes Overhauled... Korean Medical Association to Provide Consultations

Expanded Consumer Choice for Third-Party Medical Consultations on Insurance Claims
Pilot Program for Cerebrovascular and Cardiovascular Cases for Six Months
Full-Scale Implementation in the Fourth Quarter

Going forward, insurance consumers will be able to obtain medical opinions on insurance claim disputes through the Korean Medical Association rather than through insurance companies. The aim is to revise the third-party medical consultation procedure, which has so far been operated under the control of insurance companies, in order to enhance the objectivity and neutrality of the consultation results.

Lee Chanjin, Governor of the Financial Supervisory Service, and Kim Taekwoo, President of the Korean Medical Association, announced on the 4th that they had signed a memorandum of understanding (MOU) to improve the objectivity of third-party medical consultations related to insurance claims. Until now, when third-party medical consultations were conducted due to insurance claim disputes, insurance consumers had to choose a consultation institution from a list of hospitals presented by the insurance company. As most of these medical institutions had consulting contracts with insurance companies, questions were raised about the neutrality and fairness of the consultation results.

In response, the two institutions decided to establish a cooperative system that utilizes the Korean Medical Association as a medical consultation body. The Korean Medical Association plans to form a medical advisory panel consisting of at least five specialists per department, all affiliated with tertiary general hospitals or general hospitals. If an insurance consumer selects the Korean Medical Association as the consultation institution, the insurance company will request a consultation from the Association, and the Association will independently assign consulting physicians in consultation with the relevant academic societies and then send the consultation results back to the insurance company.

Insurance companies must use the medical consultation results only for the review of payment on the relevant insurance claim, and if the insurance benefit is reduced or not paid, they must explain the consultation results to the consumer. If the consumer requests it, the company must also provide a copy of the written consultation response.

This system will first be piloted for third-party medical consultations related to cerebrovascular and cardiovascular diseases and orthopedic disability under fixed-benefit insurance policies, excluding indemnity health insurance, and will then be gradually expanded. Governor Lee Chanjin of the Financial Supervisory Service said, "Medical consultations are an important basis for judgment when insurance claim disputes arise, but consumer trust has been undermined by the structure in which consultation institutions are selected mainly by insurance companies," adding, "A structure has now been established in which the Korean Medical Association, which represents medical expertise, forms medical advisory panels and consumers can choose them."

The two institutions plan to finalize detailed implementation measures within the first quarter of this year and to conduct a pilot operation in the second and third quarters for third-party medical consultations related to cerebrovascular and cardiovascular diseases and disability ratings. After reviewing the effectiveness of the system, they plan to expand the scope of medical consultations and begin full-scale operation in the fourth quarter through system development and other measures.

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