Cases of Insurance Benefit Denials Due to Strict Policy Criteria
Verification of Caregiving Service Use Is Essential for Claims
FSS Advises Careful Review of Insurance Policy Terms
# Mr. A was diagnosed with dementia at a hospital and, while receiving inpatient treatment, filed a claim for dementia caregiving expenses (diagnosis fee) insurance benefits. However, the insurance company withheld payment, stating, "According to the policy terms, dementia conditions eligible for compensation are defined as those where the insured cannot walk or eat independently, but Mr. A is able to maintain daily living activities."
# Mr. B, undergoing surgery and inpatient treatment for a fracture, used caregiving services through a company and filed a claim for daily caregiver insurance benefits. However, the insurer withheld payment, stating that it could not verify that Mr. B had paid for caregiving costs (unable to confirm caregiving expense payment details).
The Financial Supervisory Service (FSS) announced on the 9th that, as demand for caregiving insurance increases due to population aging, insurance subscribers should carefully review the policy terms regarding insurance benefit payment conditions to avoid disadvantages when filing claims.
The FSS disclosed common policy terms that insurance subscribers often overlook through major complaint cases related to caregiving insurance. First, it emphasized that if the insured does not meet the dementia condition criteria specified in the policy, dementia caregiving expenses may not be paid. It is important to note that the payment of dementia caregiving benefits follows the criteria set forth in the policy, and benefits may be denied if these requirements are not met.
An FSS official explained, "Since the policy defines conditions for payment of dementia caregiving benefits such as confirmed dementia diagnosis or dementia status, it is necessary to check the insurance benefit payment criteria when entering into an insurance contract."
The FSS also urged that it is essential to confirm payment for caregiving service usage to receive insurance benefits. If payment for caregiving services is not verified, the definition of a caregiver under the policy may not be met, which could limit compensation.
Additionally, if verification of actual caregiver use is required, the insurer may request submission of additional supporting documents. If basic claim documents do not clearly demonstrate actual use of caregiving services, the insurer can demand further documentation to confirm this.
An FSS official stated, "When using caregiving services, it is important to meticulously keep evidence and records that can verify actual caregiver use to avoid disadvantages."
Furthermore, if the policy’s daily caregiver use clause excludes coverage for integrated nursing and caregiving services, insurance benefits may not be paid, so it is important to carefully review the terms of the subscribed insurance contract.
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