[Becoming an Insurance Insider] Long-term Care Hospitalization Fees... Who Pays? Who Doesn't?

Controversy Over Payment for Long-Term Care Hospitalization Fees

[Asia Economy Reporter Oh Hyung-gil] Amid ongoing disputes over cancer insurance coverage for long-term care hospital inpatient fees, criticism arises over why some receive insurance payouts while others do not.

However, it is pointed out that it is not a matter of uniformly deciding whether long-term care hospital inpatient fees fall 'under' or 'do not fall under' cancer hospitalization benefits. The conclusion may vary depending on whether the long-term care hospital admission was indispensable for cancer treatment.

According to the Financial Supervisory Service on the 7th, 2,125 complaints related to cancer hospitalization fees were filed in 2018, which significantly contributed to the increase in complaints against life insurance companies compared to the previous year. In particular, in September last year, the insurance company won a lawsuit filed by the representative of the 'Cancer Patients Group Responding to Insurance Companies' regarding long-term care hospital inpatient fees.

Baek Young-hwa, a research fellow at the Korea Insurance Research Institute, pointed out, "According to the terms and conditions of cancer insurance products that cover cancer hospitalization fees, not all hospitalizations related even slightly to cancer result in insurance payouts. Insurance benefits are payable only if the insured is diagnosed with cancer after the cancer coverage start date and is hospitalized directly for the purpose of treating that cancer."

The court recognized that cases involving the removal of cancer, suppression of cancer proliferation, or improvement of serious pathological symptoms directly caused by the cancer itself or its growth are considered hospitalizations for the direct purpose of cancer treatment.

On the other hand, cases aimed at alleviating sequelae caused by cancer or its treatment or treating complications are not recognized as hospitalizations for the direct purpose of cancer treatment.

[Image source=Yonhap News]

Determining Whether It Is Indispensable for Cancer Treatment Is Not Simple

In dispute mediation cases by the Financial Supervisory Service, it was judged that long-term care treatment hospitalizations for treating sequelae or complications occurring after cancer treatment or for health recovery are difficult to recognize as hospitalizations for cancer treatment purposes.

However, if chemotherapy of the same nature continues for a certain period, and hospitalization to treat sequelae caused by previous chemotherapy and to restore physical function is indispensable for receiving upcoming scheduled chemotherapy, it is regarded as hospitalization for cancer treatment purposes.

Research fellow Baek said, "If during ongoing cancer treatment, admission to a long-term care hospital for immune system enhancement or sequelae treatment is indispensable to continue future cancer treatment, such long-term care hospital admission would also be considered hospitalization for cancer treatment. However, even in this case, determining whether long-term care hospital treatment is indispensable for ongoing cancer treatment is neither simple nor clear."

He added, "Judgment should be made based on specific facts in each case, such as the patient's condition, whether inpatient treatment is necessary, the content and methods of treatment at the long-term care hospital, and the doctor's opinion."