This year, insurance companies have been winning lawsuits over cataract insurance payments one after another. The court ruled that even if cataract surgery falls under the Daesang payment system, it does not necessarily recognize the hospitalization for cataract surgery. In the future, patients who have undergone cataract surgery will find it more difficult to receive insurance payouts unless complications or side effects occur after the surgery, or unless it is assessed that there is a high likelihood of such occurrences.
The Daesang payment system refers to the system of bundling all medical expenses incurred from admission to discharge for specific diseases and paying a predetermined amount. It is essentially a system based on inpatient treatment. Patients assert that since cataract surgery is covered by the Daesang payment system, the insurance company should pay for hospitalization expenses.
On June 6, ChosunBiz identified 24 first and second trial rulings on cataract insurance cases disclosed by the Supreme Court this year, noting that there were no instances in which patients won.
The core of the cataract insurance payment controversy is whether cataract surgery requires hospitalization. The insurance compensates 250,000 won for outpatient treatment but compensates 50 million won for inpatient treatment. This has led hospitals to encourage patients who have undergone cataract surgery to be discharged after 6 hours since only hospitalization longer than 6 hours is recognized under the terms.
As cataract surgery was pointed out as a cause of insurance payout leakage, insurance companies intensified their payment review process. If a patient returns home within 2 to 3 hours after surgery, it will not be recognized as hospitalization. Additionally, even if the 6-hour condition is met, if a patient was hospitalized for reasons only needing ‘management,’ the insurance payment will not be made.
On the other hand, patients argue that because the Daesang payment system applies to cataract surgery, even those discharged after 2 to 3 hours of hospitalization should be recognized as hospitalized. As the controversy continued, thousands of patients began filing lawsuits against insurance companies starting in the second half of last year.
Considering the rulings delivered this year, the court views cataract surgery as treatment that does not require hospitalization. Regardless of the differences in surgical methods between patients, as the complications are minimal, there is no need for continuous observation or management. This means that the necessity for hospitalization is only recognized in exceptional cases where complications or side effects arise after surgery. Furthermore, the court ruled that the application of the Daesang payment system to cataract surgery is solely for ‘policy reasons,’ and thus cannot justify recognizing the hospitalization.
Recently, rulings in which patients had won are being overturned. The Civil Division 5-2 of the Seoul Central District Court (presided over by Director General Yeom Gi-chang) on January 15 canceled the first ruling that awarded A his insurance payment in a lawsuit he filed against the insurance company regarding the cataract surgery, siding with the insurance company. The court noted that many ophthalmology hospitals promote that ‘it takes about 2 to 3 hours for discharge on the same day after surgery,’ stating, “It does not seem to require hospitalization as it necessitates continuous observation and management by medical staff for more than 6 hours.”
Regarding the Daesang payment system, the court stated, “In the case of phacoemulsification surgery, it is acknowledged that the Daesang payment system applies even if the patient is discharged on the same day after less than 6 hours of observation.” However, it also noted, “It appears that the requirement of ‘6 hours observation after surgery’ has been exceptionally excluded due to policy reasons to apply the Daesang payment system.” Thus, it concluded, “Regardless of whether there was actual hospitalization, the court cannot recognize that the plaintiff (A) was admitted solely based on the fact that the Daesang payment system applies.”
An insurance industry official noted, “It has become established that the necessity for hospitalization is not recognized if there are no complications or side effects from cataract surgery.” They added, “Insurance policyholders should consider that they may not receive insurance payments and weigh the cost of treatment and the necessity of surgery, which is the most realistic approach.”