When subscribing to insurance, consumers are guaranteed coverage for various types of illnesses. Consumers have been frequently complaining that they weren’t able to receive insurance proceeds after making health insurance claims. 

 

This may be due to the fact that the scope of coverage is limited under the actual insurance contract terms different from what was explained to would-be subscribers. Another cause may be that the development of medical technologies is leading to rising number of surgeries which do not require patients to be hospitalized. However, insurance companies do not cover these types of surgeries, making it difficult for the covered to receive insurance proceeds. 

 

This prompted the Korea Consumer Protection Board (KCPB) to analyze 121 redress cases related to health insurance reported between January and March 2006. KCPB concluded that policy improvements were needed regarding payment criteria of insurance proceeds. 

 

Unit: Number of Cases (%)

 

Other complaints relate to insurance companies’ wide or narrow interpretation of ‘surgery’ and insurance companies applying unrealistic standards that don’t reflect the development of medical technology that prevents those covered from receiving insurance proceeds.  

 

Despite the fact that surgeries that don’t require hospitalization are increasing due to the development of medical technologies such as polypectomy, insurance companies tend to only cover surgeries that require hospitalization, which is another type of complaint. 

 

There are some insurance companies that mislead would-be subscribers to think that its products guarantee all types of illnesses or include information on its product guidebook that all types of diseases are covered such as cerebral apoplexy, gynecology disease and chronic women’s disorders. 

 

In reality, however, insurance companies leave out most of the diseases from the coverage scope and apply complicated regulations on diagnosis. 

 

Based on the above findings, KCPB will propose to relevant institutions such as the Financial Supervisory Service (FSS) to ▲enlist specific names of illnesses in the Insurance Guide instead of comprehensive names that could mislead consumers ▲ease diagnosis requirements of insurance companies regarding serious illnesses such as cerebral diseases ▲ improve criteria for payment of insurance proceeds and revise contract terms that reflect development of medical technologies. 

 

Furthermore, KCPB advised consumers to ▲carefully go over the criteria under the contract before signing ▲check the requirements and scope of coverage after receiving diagnosis ▲keep doctor’s diagnosis to request payment of insurance proceeds.

 

Source: Consumer Dispute Settlement Department I