The insurance industry has come up with consumer protection measures as complaints from subscribers that they did not receive medical loss insurance (indemnity insurance) even following undergoing cataract surgery through due process increased. The insurance industry plans to prevent disputes related to insurance claims by operating a related call center and disclosing criteria for selection of medical investigation subjects.
The Life and Non-Life Insurance Association announced on the 6th that it plans to operate a ‘cataract surgery indemnity insurance consultation call center’ by the end of this year for each insurance company to reduce disputes related to the payment of indemnity insurance. Through the call center, subscribers can receive information on items that need to be checked and requested when visiting an ophthalmologist, insurance payment review procedures, and cataract surgery insurance products.
The background to the insurance industry’s consumer protection measures lies in the excessive treatment of cataracts and the stricter insurance payment review. The insurance industry believes that some hospitals and clinics have recently induced unnecessary cataract surgery, so insurance money leakage has reached a serious situation. In fact, the amount of cataract-related loss insurance paid by insurance companies in the first quarter of this year reached an all-time high of 457 billion won.
For this reason, insurance companies have requested ‘medical advice’ to a third-party medical institution to determine whether the insurance claim is justified. As the amount of indemnity insurance leaks increased, the number of medical advice cases (2348 cases in 2020 → 22,589 cases last year) and the number of non-payment cases (436 cases → 1,036 cases) also increased.
The problem is that even consumers who have legitimately had cataract surgery are not receiving insurance payments, so complaints regarding it are on the rise. In addition to operating the call center, the insurance industry announced that it would thoroughly abide by the ‘insurance fraud prevention model standards’, such as △disclosure of the selection criteria for investigation, △mandatory explanation of the reasons for requesting medical advice, and △guides on damage relief procedures.
An official from the Non-life Insurance Association said, “We plan to extend the special reporting system for cataract insurance fraud, which gives a reward of up to 30 million won, until the end of this month to prevent leakage of actual loss insurance money.”
Park Joo-hee reporter jxp938@hankookilbo.com