A court ruling stated that the expenses incurred from play therapy conducted by a play therapist with a private qualification for children with developmental delays are not subject to insurance payments. The court determined that such play therapy by a private qualifier is not legally considered a 'medical practice.' Treatment for children with developmental delays is diverse, including language, cognitive, art, play, and sensory integration therapies; however, since there are no national certifications for art and play therapy, private qualifiers have been providing those treatments. As a result, the likelihood of art and play therapies not being eligible for insurance payments has increased.
The amount of the lawsuit (the case value) is 5.42 million won, but the interest from the insurance industry is significant. If the insurance company had lost, it could have shaken the logic surrounding non-payment of insurance claims in the insurance industry. The coalition for the rights of families of children with developmental delays, who filed the lawsuit, enlisted lawyer Han Bu-hwan, a former Vice Minister of the Ministry of Justice, while Hyundai Marine & Fire Insurance appointed a lawyer from Kim & Chang, escalating the matter to a clash between former officials and large law firms.
According to the insurance industry on the 11th, the 37th Civil Division of the Seoul Central District Court (Director General Lee Hyo-jin) dismissed A's insurance claim for 5.42 million won in actual expenses, ruling that Hyundai Marine & Fire Insurance has no obligation to pay.
Previously, after A's child was diagnosed with developmental delays in September 2022, A received language therapy from a speech rehabilitation therapist, sensory integration therapy from an occupational therapist, and play therapy from a play therapist at a psychological development center of a hospital. Subsequently, A filed a claim with Hyundai Marine & Fire Insurance for out-of-pocket medical expenses through the insurance policy he purchased.
Hyundai Marine & Fire Insurance had been paying A 37 million won in insurance benefits but stopped payments for play therapy starting in June 2023. The court deemed that play therapy falls under medical practice, yet the play therapist involved held a private qualification, thus not being classified as a medical professional. In contrast, A contended that there is no national certification examination system for play therapy, leaving him no option but to seek treatment from these providers.
The court stated, "Medical practices can only be performed by medical professionals or by individuals who have acquired qualifications to assist medical practices in accordance with health care laws; the qualification requirements are strictly defined and cannot be broadly interpreted."
In particular, it stated, "The lack of a separate qualification examination system for play therapists by the state and other reasons alone do not allow for equal status to be granted to play therapists as those qualified to assist medical practices."
The controversy over insurance payments for developmental delays began after COVID-19. As children unable to engage in outdoor activities during the pandemic experienced developmental delays, various hospitals began promoting treatments under signs like "Child Development Clinics," leading to a surge in claims for insurance benefits. Some hospitals recommended treatments to parents, stating that "claims for actual expense reimbursement are possible, so the burden is not significant."
As the fact that treatment for developmental delays could be monetarily beneficial spread, illegal medical practices began to emerge, including offices using medical professionals as 'fronts.' Attempts at document forgery also arose, with false diagnoses for children not experiencing developmental delays. Specialized brokers appeared, offering to design these profit-making schemes, asking for half of the sales revenue.
A representative from Hyundai Marine & Fire Insurance commented on the ruling, stating, "This reaffirms the principle that actual expense insurance is guaranteed based on the definition of 'medical practice' under medical law." The representative also expressed hope that good-faith victims would not miss critical treatment windows due to certain unqualified medical practices.
The coalition for the rights of families of children with developmental delays is considering an appeal. Representative Song Su-rim noted, "It is perplexing that a completely different outcome has emerged despite rulings on similar cases," adding that "having received diagnoses and prescriptions from a doctor for treatments, it is upsetting to be compared to illegal medical practices."