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Experts call for more transparent operation of medical insurers
  • By Lee Min-ju
  • Published 2017.06.30 18:40
  • Updated 2017.09.22 13:17
  • comments 0

Private insurance companies make requests for “medical advice” related to insurance payment to only specific hospitals and doctors, and don’t pay money in nine of 10 cases based on such advice, an expert says.

And that causes an increasing number of consumers to apply for remedy, he noted.

The expert made these and other points at a seminar Wednesday hosted by Korea Consumer Agency (KCA)한국소비자원 to seek ways to develop consumer damages relief and dispute mediation systems, pointing out the problems in underwriters’ seeking medical advice and information disclosure.

“The number of damage relief cases related to insurance benefits has sharply increased,” said Cho Jae-bin조재빈, deputy manager at the finance and insurance team in KCA. “Last year, we accepted 1,363 cases, an increase of 65.8 percent from 2015.”

Korea Consumer Agency holds a seminar to seek the means to develop consumer damage relief system and dispute mediation system, at the AT Center in Yangjae-dong, southern Seoul, Wednesday.

Out of the total 1,674 cases, including those registered in the first quarter of this year, 1,158 cases, or 69.1 percent, were damages caused by insurance benefit payment, or lack thereof, Cho added.

“In 267 cases, or 23.2 percent of the total, insurance firms didn’t pay benefits or paid them only in part under the pretext of the medical advice,” the official said. “Most insurance companies have concentrated their requests for advice only on some hospitals in common, or even the same doctors.”

Moreover, these insurers have failed to make public information related to these advisory hospitals and doctors.

These insurance companies refused to pay “not a penny” in 220 cases, or 85.6 percent of the 257 cases whose advisory results had been confirmed. In the other 33 cases (12.8 percent), underwriters paid only part of the money. In only four cases (1.6 percent), they paid in full.

“As insurance companies seek advice from a few specific hospitals, objectivity can be a problem,” Cho said. “They don’t reveal advising doctors and the contents of advice at all, failing to ensure the objectivity and fairness of such advice.”

He then called for insurers to make public information related to reasons for requesting insurance money, the number of requests for advice, advising doctors and advisory results.

However, the insurance industry said all this is due to the limitations of consulting workforce, asking Korean Medical Association (KMA)대한의사협회 to cooperate for providing the advice.

“We are aware of concentrated requests for advice, but this is the problem resulting from the insufficient pool of advisory doctors to whom insurers can turn,” said Kim Jin-ku 김진구, chief of the assessment department at Samsung Life Insurance삼성생명보험. “It 'd be nice if KCA and KMA to help us seeking the advice.”

However, he expressed negative positions on the disclosure of advisory information.

“If we reveal the information, people might visit the doctors and behave rudely to them,” Kim said. “If so, it will be harder to secure advising physicians and hospitals.”

A KMA executive agreed. “When we underwent dispute mediation process, we wondered who gave the advice. Even though advising doctors treated patients based on academic knowledge, people more often than not acknowledge it,” said Kim Jin-ho김진호, director for insurance at KMA. “Advisors may be in trouble, however, if their information is made public. If their names are disclosed, they will find it hard to respond to requests.”

Kim, however, went on to say, “The insurance companies should have asked for advice from doctors from when they made terms and conditions. Does it make sense to arbitrarily set terms and conditions and say they leave judgments to only physicians? For impartial advice, they should form a consultative body, respect doctors’ anonymity and pay appropriate fees to them.”

A parliamentary official also suggested a solution. “Currently, the court and prosecutors get advice from KMA. Objectivity and fairness for advice will be guaranteed if they expand its application to medical advisory activities,” said Kim Chang-ho김창호, a legislative investigator at National Assembly’s Research Service(NARS)국회 입법조사처. “One of the good ways is to hire retired doctors who have many experiences and in-depth knowledge as advisors.”


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