"Doctor Wrote 'Hospitalization Appropriate'... Allegations of Distorted Medical Reviews in Private Health Insurance"

Professor Sanghyun Ahn: "Wording in Advisory Opinion Was Delivered in the Exact Opposite Manner"

Structural Flaws Allow Insurers to Intervene in and Control Medical Judgments

Pharmaceutical Sovereignty Solidarity Calls for Full Investigation

Allegations have surfaced that, during the "medical advisory" process to determine insurance payouts after varicose vein surgery, the opinions of consulting physicians were altered to state the exact opposite of their original intent. Patient and consumer organizations have labeled this a "nationwide fraud" that betrays the trust of 40 million policyholders with indemnity health insurance, and have called for an immediate, comprehensive investigation by financial authorities.

On the 20th, at the Korea Consumer Federation Seoul Branch in Hannam-dong, Yongsan-gu, Seoul, Professor Sanghyun Ahn, a surgeon at Seoul National University Hospital, is speaking at the "Pharmaceutical Sovereignty Patient and Consumer Solidarity Press Conference". Photo by Jo Inkyung

The "Pharmaceutical Sovereignty Patient and Consumer Solidarity" and the Korean Society of Phlebology held a press conference at the Korea Consumer Federation Seoul Branch in Hannam-dong, Yongsan-gu, Seoul, on the 20th, where they disclosed specific cases and testimonies showing that the results of medical consultations requested by insurers had been altered from the original documents.

At the event, Professor Sanghyun Ahn, a surgeon at Seoul National University Hospital, publicly revealed both the medical advisory document he wrote and the notification the patient received. He explained, "I provided an expert opinion requested by the insurer, stating that 'one day of inpatient treatment is appropriate.' However, the notification sent to the patient contained the exact opposite, stating, 'hospitalization is unnecessary and is merely an administrative process.'"

Professor Ahn further stated, "In particular, the negative phrases in the notice given to the patient appear to have been copied directly from language I used in other, unrelated cases in the past," and added, "Medical professionals' expert opinions are being reconstructed to suit the insurers' interests."

The closed structure of "medical advisory intermediary agencies," which act as middlemen between insurers and consulting physicians, was also cited as a factor enabling such distortions. Currently, medical advisory documents are exchanged in editable formats, making it impossible to verify if any terms are inserted or changed during the process.

Consumer A (female, age 56), who was directly impacted by this case, said, "When I was first informed by the insurer that 'hospitalization was not justified' based on their advisory, I suffered significant psychological distress. It was only after seeking a second opinion at another university hospital that I was able to receive my insurance payout. Through this process, I discovered that the insurer had distorted the advisory from the outset."

This issue came to light when another physician, who provided a third-party consultation for consumer A, reviewed the original medical advisory notification and directly confirmed its contents with Professor Ahn. Since the names of consulting physicians are not revealed in the advisory documents, parties usually do not know each other's identities. However, in cases involving certain hospitals or illnesses, it is possible to deduce the physician involved due to a limited pool of specialists. Professor Ahn reported this to the Korean Society of Phlebology, which then confirmed there were additional similar cases and decided to bring the matter to public attention.

Taesik Kim, President of the Korean Society of Phlebology and Professor at Korea University Guro Hospital, criticized, "Statistically, there has been a steady increase in cases where insurance payouts are fully or partially denied based on medical advisory opinions. This demonstrates that medical advice is being abused as a tool to reject insurance claims." He added, "This issue is not a simple dispute over insurance payouts but exposes a structural problem that allows insurers to intervene in and control medical judgments," pointing out that "the credibility of indemnity health insurance, which serves as a public safety net, has been undermined."

The Society and the Solidarity group delivered five key demands to financial authorities and the National Assembly: full disclosure of original medical advisory documents; implementation of a real-name system for consulting physicians; establishment of an independent third-party medical review board; prohibition of edits or modifications to advisory documents and management of revision histories; and an immediate, comprehensive investigation by the Financial Supervisory Service into all denied payout cases. They further defined the essence of this issue as the question of "who is responsible for altering advisory opinions," and demanded a clear explanation from the insurers.

Yongjin Kwon, Policy Chief of the Pharmaceutical Sovereignty Patient and Consumer Solidarity and Professor at Seoul National University Hospital, stated, "It is highly unlikely that insurers or medical advisory intermediaries would change the content without any vested interests. The Financial Supervisory Service should immediately launch an on-site investigation to clearly identify who changed the advisory opinions and why." Professor Kwon also emphasized, "It is essential to implement a system that fundamentally blocks the modification of advisory opinions and ensures transparency so that patients can identify who provided the advice," highlighting the need for an independent third-party review board.

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