The Korea Consumer Agency noted on the 20th that consumer disputes caused by the denial of actual medical expenses claims occurred for approximately 7 out of 10 consumers over the past four years.
According to the consumer agency, there were a total of 1,016 claims for compensation related to actual medical expenses received from 2021 to the third quarter of 2024. Among these, 789 claims (77.6%) were related to the denial of insurance payments.
Analyzing the reasons for unpaid insurance claims, it was found that cases where the necessity of treatment was not recognized accounted for the highest number at 453 cases (44.6%). Cases where the necessity for hospitalization was not acknowledged totaled 231 (22.7%), followed by 105 cases (10.3%) where reimbursement for out-of-pocket maximum was not recognized. The remaining cases totaled 227 (22.3%) for other reasons.
In particular, it was confirmed that even if consumers received treatment or hospitalization based on a doctor's judgment, insurance companies did not pay out actual medical expenses if the medical practice was not recognized as 'within reasonable discretion' based on notifications from the Ministry of Health and Welfare or medical treatment guidelines. Furthermore, for hospitalization, insurance payments were denied if there were no substantive reasons deemed necessary for hospitalization, in addition to formal conditions such as hospitalization for more than 6 hours or for more than one night.
By type of treatment, cataract surgery was the most common case with 286 (28.2%). Despite receiving inpatient treatment, many cases involved disputes over payment for only outpatient medical expenses. Manual therapy followed with 164 cases (16.1%) as the second most received treatment type. Manual therapy is often performed repeatedly, but it was confirmed that insurance companies denied payments for 'repetitive treatment.'
Although there were only 42 cases (4.1%) related to knee stem cell treatments, the number surged to 41 cases in the third quarter of this year from just one case in 2022. The majority of these cases were denied payment due to not meeting the criteria for treatments needed for arthritis or the necessity for hospitalization not being acknowledged.
The consumer agency urged consumers to ensure they obtain medical opinions regarding treatment and hospitalization situations to prevent damage from actual medical expenses. A representative from the agency said, 'If hospitalization is necessary after cataract surgery, it is crucial to secure medical opinions regarding complications or side effects,' and warned that 'since manual therapy may be denied payment if repeated, it is necessary to obtain medical records and opinions to prove the necessity of treatment if repeated treatment is unavoidable.'
He added, 'Recent increases in knee stem cell surgeries will proceed following confirmation of the osteoarthritis stage designated as a new medical technology.'
Meanwhile, the consumer agency plans to encourage hospitals to participate in the activation of claims for actual medical expenses for small medical fees. Although the insurance law amended on Oct. 25 streamlined claims for actual medical expenses related to hospital use, participation has been delayed by some hospitals citing issues with the introduction of computer systems. This insurance law is set to expand to clinics and pharmacies starting next October.