Claims for 'Cataract Surgery' Insurance Payments, Which Increased Actual Loss Deficit, Have Significantly Decreased

Reduced Cataract Surgeries Due to Stricter Insurance Claim Reviews and Government Crackdowns
Supreme Court Ruling Expected to Further Decrease Insurance Payouts for Cataract Surgeries

[Asia Economy Reporter Changhwan Lee] The amount claimed for cataract indemnity insurance, which recorded an all-time high in the first quarter of this year, has significantly decreased in the second quarter. This is analyzed as an effect of insurance companies strengthening their insurance payment reviews and financial authorities cracking down on excessive cataract treatments.

According to the insurance industry on the 20th, the scale of cataract insurance payments, which was a record high of 457 billion KRW in the first quarter, has been reduced to less than half in the second quarter. The top 10 major insurance companies, including Samsung Fire & Marine Insurance, Hyundai Marine & Fire Insurance, DB Insurance, and Meritz Fire & Marine Insurance, paid an average daily amount of 7.5 billion KRW for cataract indemnity insurance claims in March alone, but since April, this figure has reportedly dropped to the 3 billion KRW range, less than half.

This is interpreted as a result of the insurance industry and financial authorities taking active measures as excessive cataract treatments surged, worsening indemnity insurance deficits, leading to a decrease in cataract surgeries at ophthalmology clinics and hospitals.

Last year, the indemnity insurance deficit reached a record high of 2.8602 trillion KRW, and concerns grew that the deficit could exceed 3 trillion KRW this year due to cataracts. In response, insurance companies strengthened their review of cataract indemnity insurance payments, and financial authorities launched investigations into excessive cataract treatments. Additionally, a special reporting and reward system for cataract insurance fraud was introduced, and active police investigations were conducted on suspected insurance fraud cases.

A representative from a domestic insurance company said, "In the first quarter, excessive cataract treatments at some ophthalmology hospitals became severe, causing significant indemnity insurance leakage, which ultimately transferred damage to the majority of honest indemnity insurance subscribers. It appears that the effects have emerged in the second quarter as crackdowns and reviews were strengthened."

Last week, expectations grew that indemnity insurance leakage would further decrease as a Supreme Court ruling favorable to insurance companies regarding excessive cataract treatments was issued.

On the 16th, the Supreme Court Civil Division 2 upheld the lower court's ruling in favor of insurance company A in a lawsuit filed against indemnity insurance subscriber B, who underwent cataract surgery, confirming the dismissal of the appeal without oral argument.

Dismissal without oral argument is a system where an appeal is dismissed without substantive review if there is no special reason such as a serious violation of law in the lower court's decision. Previously, the second trial court judged that it was difficult to recognize that the insured patient received inpatient treatment under the indemnity insurance terms and conditions and deemed outpatient treatment appropriate.

Cataract surgery had been recognized as inpatient treatment regardless of the patient's individual treatment conditions because it was subject to a comprehensive payment system, but the Supreme Court has put a brake on this.

The insurance industry expects that due to this confirmed ruling, indemnity insurance subscribers will find it difficult to receive insurance payments for costs exceeding the outpatient treatment coverage limit, even if they receive a clear cataract diagnosis and surgery at a hospital.

Until now, even when high-cost cataract surgery fees including inpatient fees reached several million KRW, many were covered by indemnity insurance, but it is now expected that only amounts up to the outpatient treatment maximum limit of several hundred thousand KRW will be paid.

Accordingly, the amount paid for cataract indemnity insurance is likely to decrease even more significantly than now. An insurance industry official said, "With this Supreme Court ruling, the indemnity insurance payments for cataract surgery are likely to decrease significantly. Those considering cataract surgery need to check in detail in advance whether insurance payments will be made."