"'Extracorporeal Shock Wave Therapy' Not Covered by Insurance as It Does Not Meet the 'Definition of Surgery'"

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Even If Treatment Name Includes 'Surgery' or '~sul', Insurance Payment May Not Apply

#Mr. Kim visited the hospital due to chest pain, underwent coronary angiography, and filed a claim for surgery insurance benefits with the insurance company but did not receive the surgery insurance payment. Similarly, Mr. Lee underwent extracorporeal shock wave therapy for calcific tendinitis of the shoulder and filed a claim for surgery insurance benefits with the insurance company but did not receive the surgery insurance payment.

Financial Supervisory Service, Yeouido, Seoul. Photo by Younghan Heo younghan@

On the 16th, the Financial Supervisory Service (FSS) provided guidance on precautions consumers should take when claiming surgery insurance benefits based on such cases related to surgery insurance products. Surgery insurance products guarantee a specified amount defined in the policy when surgery is performed and can be obtained as a rider or additional coverage when subscribing to insurance products that cover diseases or accidents.

The FSS first stated that if the treatment does not meet the policy’s definition of "surgery," which is defined as "a procedure where a doctor uses instruments to perform cutting, excision, or similar manipulation on the living body," surgery insurance benefits may not be paid. Coronary (cardiovascular) angiography and extracorporeal shock wave therapy fall into this category.

Coronary (cardiovascular) angiography is difficult to consider as an act of cutting or excision on the living body for disease treatment, so it does not meet the policy’s definition of "surgery." However, if procedures such as coronary artery bypass grafting, which involve excision or similar manipulation on the living body, are performed concurrently during angiography to improve blood flow, surgery insurance benefits can be paid for the coronary artery bypass grafting.

Extracorporeal shock wave therapy (ESWT) also does not qualify for surgery insurance benefits. ESWT is a treatment designed to apply shock waves to the calcified shoulder tendinitis area to induce an inflammatory response that facilitates absorption of the calcific deposits. Since it is difficult to consider this as an act of cutting or excision on the living body, it does not meet the policy’s definition of surgery. However, extracorporeal shock wave lithotripsy (ESWL) is considered surgery under the policy.

An FSS official explained, "The policy defines surgery as a procedure where a doctor uses instruments to perform cutting, excision, or similar manipulation on the living body," adding, "Treatments such as ‘coronary (cardiovascular) angiography’ and ‘extracorporeal shock wave therapy,’ which do not involve cutting or excision on the living body, are not eligible for surgery insurance benefits."

Furthermore, even if the treatment name includes the term ‘surgery’ or ends with ‘~sul’ (a Korean suffix for surgical procedures), treatments involving aspiration or puncture with a syringe to withdraw fluids or inject drugs do not qualify as surgery under the policy and may not receive surgery insurance benefits.

Mr. Song underwent Avastin injection therapy for macular degeneration and filed a claim for surgery insurance benefits with the insurance company but did not receive the payment. Injection therapy is classified as a puncture procedure excluded from surgery under the policy and does not involve cutting or excision on the living body, so it is not eligible for surgery insurance benefits.

Mr. Choi also underwent autologous bone marrow aspirate concentrate intra-articular injection therapy for knee arthritis and filed a claim for surgery insurance benefits with the insurance company but did not receive the payment. The bone marrow harvesting process is close to aspiration, which is excluded from surgery under the policy, and the injection of stem cells into the knee joint is considered a puncture procedure, so it does not meet the policy’s definition of surgery involving cutting or excision on the living body, according to the FSS. However, autologous bone marrow stem cell therapy (Cartistem transplantation) is considered surgery under the policy.

An FSS official explained, "Simple aspiration and puncture procedures without cutting or excision on the living body are not considered surgery under the policy," adding, "Procedures such as ‘Avastin injection therapy’ and ‘autologous bone marrow aspirate concentrate intra-articular injection therapy,’ which involve injecting drugs or aspirating with a syringe, are not eligible for surgery insurance benefits."

Additionally, if the treatment does not correspond to the types of surgery listed in the surgery classification table in the policy, insurance benefits cannot be paid. Since the surgeries covered vary by policy, even the same treatment may result in different eligibility for surgery insurance benefits depending on the insurance plan subscribed to, so consumers should be aware of this.

For example, excision of benign skin tumors involves surgically removing benign tumors on the skin, but the surgery classification table in the policy only covers skin graft surgery related to skin operations. Therefore, excision of benign skin tumors is not eligible for surgery insurance benefits. However, if muscle layer excision was performed to remove the tumor during the benign skin tumor excision, it corresponds to musculoskeletal surgery listed in the surgery classification table and surgery insurance benefits can be paid.

An FSS official advised, "The surgery classification table in the policy lists about 100 types of surgeries, and the contents may vary by product, so please check your policy carefully before filing a claim."

Mr. Kim underwent wound suturing including marginal excision for a scalp wound and filed a claim for surgery insurance benefits with the insurance company. While he received accident surgery insurance benefits under the special accident coverage rider, he did not receive surgery insurance benefits under the special surgery coverage rider.

Wound suturing (including marginal excision) is a medical procedure that removes necrotic skin tissue and stitches damaged skin to allow natural healing. It meets the definition of surgery under the special accident coverage rider, making it eligible for accident surgery insurance benefits. However, since wound suturing (including marginal excision) is not included in the surgery classification table of the special surgery coverage rider, it is not eligible for surgery insurance benefits under that rider.

An FSS official emphasized, "Some products specifically list the types of surgeries covered in the policy, while others only define surgery without listing specific types. Therefore, even if the same treatment is received, coverage may vary depending on the product."