Analysis of Top 5 Outpatient Claims by 5 Major Non-Life Insurers
Average 285 Visits Annually, 69.46 Million KRW Claimed
4 of 5 Patients Treated for Musculoskeletal Chronic Pain
[Asia Economy Reporter Ki Ha-young] Last year, among the five domestic non-life insurance companies, four out of the five outpatients who received the highest amount of indemnity for actual medical expenses spent tens of millions of won solely on manual therapy rather than treatment for severe diseases.
According to the non-life insurance industry on the 2nd, among the subscribers of actual expense insurance at five insurance companies including Samsung Fire & Marine Insurance, Hyundai Marine & Fire Insurance, DB Insurance, KB Insurance, and Meritz Fire & Marine Insurance last year, the top four recipients of outpatient actual expense insurance claims were patients with chronic musculoskeletal pain. The average insurance payout for the top five outpatient claimants was 69,458,000 KRW, with an average of 285 outpatient visits. Non-reimbursed medical expenses accounted for 95% of the claimed amount.
The top recipient of outpatient medical expense insurance, Mr. A (30), received outpatient treatment 252 times last year due to pain in his limbs. 97% of the insurance payout to Mr. A last year was for non-reimbursed medical expenses, totaling 74,197,000 KRW.
Mr. B (72), who ranked second in insurance payout, received treatment 307 times and was paid 74,161,000 KRW. Mr. B complained of chronic musculoskeletal pain due to old age and received concentrated manual therapy at clinic-level facilities.
Mr. C (52) was diagnosed with "Other specified intervertebral disc displacement" and received manual therapy and extracorporeal shock wave therapy 308 times at clinic-level facilities, receiving 71,581,000 KRW in insurance payouts. The diagnosis refers to spinal deformities and pain in areas such as a straight neck. Mr. D (53) received 67,704,000 KRW in insurance payouts for manual therapy and injection fees.
Among the top five insurance payout recipients, the only patient with a severe disease was a 53-year-old breast cancer patient who received the fifth highest medical expenses (60,148,000 KRW).
All of these high-amount insurance recipients are subscribers to either the first-generation deductible actual expense insurance or the second-generation standardized actual expense insurance, which have low out-of-pocket ratios of 0 to 20%.
Non-reimbursed medical treatments are entirely subject to the discretion of medical institutions regarding usage and costs, leading to a surge in claims. The non-reimbursed rehabilitation and physical therapy expenses paid by the five non-life insurers nearly doubled from 239.2 billion KRW in 2018 to 471.7 billion KRW last year. Manual therapy has indiscriminately increased and is now being performed in pediatrics, dermatology, and obstetrics and gynecology, with claims even emerging from dentistry, which is not a medical specialty.
The excessive use of non-reimbursed treatments by a small number of patients shifts the insurance premium burden onto all actual expense insurance subscribers. While losses exceeding 3.5 trillion KRW are expected from actual expense insurance alone this year, the non-life insurance industry recently submitted opinions and evidence to the Korea Insurance Development Institute stating that for first-generation products, premium increases of over 15% will be necessary next year as well, similar to this year.
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