Allegations have been raised that, in the medical consultation process—a key step that determines whether insurance benefits are paid—the opinion written by the consulting physician and the content the insurer delivered to the consumer differed.
Patient and consumer groups urged system reforms, saying insurers may have altered or downplayed the medical consultation findings to deny insurance payouts.
The Medicine Sovereignty Patients and Consumers Alliance, made up of the Korea Consumer Federation (Secretary-General Jeong Ji-yeon), the Korea Alliance of Patients Organization (Representative An Gi-jong), Consumers Union of Korea (Secretary-General Yun Myeong), and the Korea Organization for Rare Diseases (Secretary-General Jeong Jin-hyang), held a press conference on the 20th at the Korea Consumer Federation's Jeong Gwang-mo Hall in Seoul and made this claim.
◇ Claim: "Original consultation and notification letter differ"
They said it was confirmed that the medical consultation, which serves as the basis for deciding insurance payouts, may have been altered, reduced, or reconstituted into different content during internal transmission at the insurer. As a result, the decision on payouts could be distorted by the insurer's internal decision-making structure rather than by medical judgment.
They presented an actual case involving varicose vein surgery. The consulting physician's opinion included the statement, "Given varicose vein treatment guidelines and the nature of the surgery, a one-day inpatient treatment is appropriate and is also reasonable for treatment purposes and to prevent complications."
However, the notification letter sent to the patient included language to the effect that "as an outpatient-based short procedure, the need for hospitalization is not established," with added phrasing that could be interpreted as denying the need for treatment.
A woman in her 50s, a consumer who said she was harmed and attended the event, said she confirmed coverage with the insurer before undergoing varicose vein surgery but was later denied payment.
She said she requested a review, received a determination from a separate medical institution that the treatment was appropriate, and was then paid the insurance benefits, adding that she suffered for more than a month during the process. "In the end, the fact that I received the insurance benefits shows the initial decision was wrong," she said.
◇ Medical community: "Confirmed cases where the meaning was delivered in the opposite way"
Kim Tae-sik, president of the Korean Society for Phlebology, said, "We confirmed that the medical consultation opinion written by the consulting physician and the result communicated to the patient were contradictory," adding, "There are additional similar cases."
Kim said, "Insurers typically decide on payouts based on the consulting physician's opinion, but this case suggests the content may have been altered in the middle," noting, "This needs to be identified as a structural problem."
An Sang-hyeon, a professor of surgery at Seoul National University College of Medicine, also said, "We sent a consultation opinion deeming the treatment appropriate, but the patient's notification letter recorded a completely opposite meaning." He said, "It appears that wording used in a past, different case was inserted to the patient's disadvantage," adding, "It is also possible it was modified by an intermediary or the insurer."
Kang Jeong-hwa, president of the Korea Consumer Federation (co-leader of the Medicine Sovereignty Patients and Consumers Alliance), said, "Discussions on system reforms to improve fairness and trust in insurance payouts have continued, but similar cases are repeating," adding, "Consumer distrust is growing that insurers are using medical consultations as a means to deny payouts," and argued, "A review of all nonpayment cases is needed."
Kwon Yong-jin, policy director of the Medicine Sovereignty Patients and Consumers Alliance (professor at the Public Healthcare Center, Seoul National University Hospital (SNUH)), pointed out, "Even though the General Insurance Association of Korea and medical societies operate pools of consultants, insurers are not making proper use of them." He argued, "The Financial Supervisory Service should investigate and file complaints, and system reforms are needed, including a system to prevent revisions to consultation opinions and the establishment of an independent review body."
The groups defined this issue as a structural problem rather than a simple insurance payout dispute and presented reform demands. Specifically, they called for: ▲ full disclosure of original medical consultations ▲ adoption of a real-name system for consulting physicians ▲ establishment of a third-party medical review and deliberation body independent of insurers ▲ a ban on revising or editing consultation documents and disclosure of revision histories ▲ a full-scale probe by financial authorities into nonpayment cases.
An Gi-jong, head of the Korea Alliance of Patients Organization, said in the press statement, "There is growing suspicion that medical consultations are functioning not as an objective review procedure but as a means to deny insurance payouts."