'Stent' and 'Cheoechunggyeokpa', Why Can't You Receive Surgery Insurance Benefits?

"Opening and Amputating or Resecting Body Parts for Treatment Purposes"

The Financial Supervisory Service has warned consumers that coronary angiography, extracorporeal shock wave therapy, and knee injections are not covered under surgical insurance benefits. Surgical insurance benefits are only paid when treatment falls under the definition of surgery as specified in the insurance policy. So, what exactly does this 'surgery' encompass?

Generally, surgery refers to the act of opening a part of the body for treatment purposes, involving cutting, excising, or manipulating the human body. It involves incising and opening the body, allowing medical instruments to invade inside. The term 'procedure,' often confused with surgery, involves inserting an endoscope or catheter into the body but does not include cutting or manipulating the body.

In insurance policies, surgery is defined as an act involving the use of medical instruments for treatment purposes that includes cutting, excising, or manipulating living tissue. Even if the treatment name includes the word 'surgery' or ends with '~sul' (meaning 'surgery' in Korean), it does not necessarily qualify as surgery under the policy. Treatments such as suturing wounds or filling teeth with inert materials do not count as surgery here. Even if a part of the body is removed, procedures like inserting and removing a syringe or tube are not considered surgery under the policy.

For example, coronary angiography, cited by the Financial Supervisory Service, involves injecting a contrast agent into the coronary arteries or cardiovascular system to examine blood vessels. However, it is difficult to classify this as surgery since it does not involve cutting or excising living tissue for disease treatment, thus it does not meet the policy’s definition of surgery. However, if a coronary artery bypass graft surgery is performed during angiography to improve blood flow, it is classified as surgery.

Professor Kim Byung-geuk of the Cardiology Department at Severance Hospital explained, "In vascular treatment, a procedure refers to inserting a catheter through the skin’s blood vessels without general anesthesia," adding, "Surgery is generally distinguished by whether an incision is made." He further stated, "If the blood vessel is not just punctured with a needle but is cut open and directly visualized, it can be considered surgery. Coronary artery bypass graft surgery involves cutting the skin and bone and entering the heart, so unlike a typical stent, it must be regarded as surgery."

There are cases where a part of the body is cut and classified as surgery but is mistaken for a procedure. This is commonly called 'endoscopic spinal disc procedure.' A herniated disc occurs when the disc deteriorates due to aging, trauma, or poor lifestyle habits, causing micro-damage and protrusion that irritates and compresses surrounding nerve roots, resulting in pain.

In herniated disc surgery, the protruding disc portion is removed through an endoscope. Since it causes changes to the body, it is classified as surgery, but due to the strong perception that "no knives should touch the back," it is usually called and promoted as a procedure. However, treatments that do not remove the disc but only separate the part touching the nerve without changing the body are classified as procedures.

A neurosurgeon working at a hospital in the metropolitan area said, "Actions like removing or decompressing the disc are all surgeries, but reducing the size with electric waves is classified as a procedure, so there are many different cases," adding, "Because of such ambiguity, some hospitals call surgeries procedures, so if you want to know about insurance coverage, you should check precisely with the hospital and get accurate guidance."

Conversely, some acts that appear not to involve opening a part of the body are actually surgeries because the body is opened during the process. Surgeries on parts of the body exposed externally, such as plastic surgery, LASIK surgery, and skin cancer surgery, fall into this category.