Financial Supervisory Service Discloses Consumer Complaints on Accident and Health Insurance Cases
Office worker Mr. Im was hit on the head by a falling tree while walking. He received wound suturing surgery at the hospital. Afterwards, he filed a claim for surgery insurance benefits, but the payment was denied.
Surgery insurance benefits are paid only when treatment corresponds to the definition of surgery as specified in the policy terms. The policy defines surgery as an act involving the use of medical instruments for treatment purposes that includes operations such as cutting or excision on the living body. Even if the treatment name includes the word "surgery" or ends with "~sul" (surgery), it does not necessarily qualify as surgery under the policy.
On the 23rd, the Financial Supervisory Service disclosed precautions related to injury and disease insurance that covers illnesses and injuries occurring to the insured person's body.
Mr. Jang was hospitalized for 180 days at Hospital A due to a brain hemorrhage caused by a fall accident, then transferred to Hospital B and filed a claim for injury hospitalization daily allowance insurance benefits. The insurer paid benefits only for the hospitalization at Hospital A and denied the claim for Hospital B. Hospitalization expenses have limits on the number of payable days, such as six months, as specified in the policy. Two or more hospitalizations for the treatment of the same injury (disease) are considered as one continuous hospitalization, and the days of each hospitalization are summed for calculation.
Mr. An was hospitalized in a convalescent hospital after cancer surgery and received convalescent treatment beneficial for alleviating aftereffects and boosting immunity, unrelated to chemotherapy. He later filed a claim for hospitalization daily allowance insurance benefits, but it was denied. If the hospitalization is not directly for disease treatment, such as alleviating cancer aftereffects, hospitalization insurance benefits may not be paid.
Mr. Kim was clinically presumed to have carcinoma in situ at the hospital. He then filed a claim for cancer diagnosis insurance benefits, but the payment was denied because there was no pathological tissue examination result that could be considered a definitive diagnosis. If a diagnosis confirmation according to the method specified in the policy is not obtained, insurance benefits may not be paid.
Mr. Lee was diagnosed with cerebrovascular disease and filed a claim for diagnosis insurance benefits, but the payment was denied. This was because the medical records he submitted, such as imaging interpretation reports, did not contain sufficient evidence to determine cerebrovascular disease.
Mr. Choi filed a claim for disease aftereffect disability insurance benefits due to spinal disability caused by lumbar disc herniation, but the payment was denied. It was confirmed that he had been diagnosed with the same degree of spinal disability in the same area before insurance enrollment. If aftereffects already existed before insurance enrollment, aftereffects occurring in the same area may not be paid or may be partially paid considering this fact.
A Financial Supervisory Service official stated, "Whether insurance benefits are actually payable depends on individual insurance policy terms and specific facts, so it is essential to check the relevant policy and other details."
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