Compensation Possible for Similar or Identical Existing Technologies
Measures to Prevent Excessive Insurance Company Lawsuits Established
"Actively Utilize HIRA's Non-Covered Medical Expenses Verification System"
Insurance companies will no longer be able to arbitrarily deny indemnity medical insurance claims for treatments involving new medical technologies. If a medical device has only been simply modified or is essentially the same technology as an existing one, insurance claims must be paid.
On the 25th, the Financial Supervisory Service announced that it will revise the claim review standards for indemnity insurance based on these principles. This is due to concerns that insurance companies might uniformly reject claims related to new medical technologies or excessively file lawsuits against patients.
Accordingly, the claim review standards for indemnity insurance will be revised to ensure thorough verification of policy terms, precedents, and the results of non-reimbursable medical expense confirmations by the Health Insurance Review and Assessment Service during claim assessments.
Indemnity insurance policies define the coverage targets as the patient's co-payments and non-reimbursable expenses under the Health Insurance Act's medical benefits. Therefore, medical procedures classified as discretionary non-reimbursable are not covered by indemnity insurance. However, if the relevant medical technology is essentially similar or identical to an existing technology whose safety and efficacy have been proven, it can be compensated as statutory non-reimbursable.
For example, cases where ▲a medical device has been simply modified within the same category as the existing one ▲the court has determined through precedent that the technology is essentially identical to existing technology ▲the Health Insurance Review and Assessment Service's review confirms it as existing technology are recognized as similar or identical technologies.
Furthermore, if a medical institution proves the urgency of the treatment, medical necessity, and patient consent?requirements recognized by the Supreme Court?even discretionary non-reimbursable medical procedures can be compensated.
Measures will also be taken to prevent insurance companies from excessively filing civil lawsuits against patients. Before filing a lawsuit, insurance companies must guide consumers to use the Health Insurance Review and Assessment Service's 'Non-Reimbursable Medical Expense Confirmation System' and must verify the results.
By using this system, patients can confirm whether the treatment is statutory non-reimbursable and, if applicable, receive indemnity insurance payments from the insurer; if it is discretionary non-reimbursable, they can seek reimbursement directly from the medical institution. Only in exceptional cases, such as when a patient refuses to use this system, can the insurer proceed with litigation.
Additionally, procedures will be improved to regularly monitor the appropriateness of lawsuits through bodies such as the Litigation Management Committee.
A Financial Supervisory Service official stated, "Consumers should carefully verify the safety and efficacy of new medical technologies and the indemnity insurance compensation standards before treatment to avoid inconvenience," and urged, "Please actively use the Health Insurance Review and Assessment Service's Non-Reimbursable Medical Expense Confirmation System when necessary."
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