Out-of-Pocket Maximum Benefits Given Even to Major Delinquents Over Five Years
"Legal Revisions Needed to Address Systemic Loopholes"
A loophole has been revealed in the system that allows refunds under the out-of-pocket maximum policy to be provided even to those who are in arrears on their health insurance premiums. It has been confirmed that there are numerous cases where individuals have received medical expense refunds worth hundreds of millions of won without paying tens of millions of won in insurance premiums.
According to data submitted by the National Health Insurance Service to Assemblywoman Seo Mihwa of the Democratic Party of Korea, a member of the National Assembly's Health and Welfare Committee, on September 24, individual A did not pay 14,479,000 won in health insurance premiums over a total of 18 months from 2020 to last year, yet received a refund of 15,766,000 won in medical expenses through the out-of-pocket maximum policy.
The out-of-pocket maximum policy is a system in which, if a patient's health insurance-covered medical expenses exceed a certain threshold set according to income level (ranging from 870,000 to 10.5 million won in 2024), the excess amount is refunded from the health insurance fund. The policy was introduced to prevent excessive medical expenses from becoming a burden on households. However, under current law, there is no provision allowing the deduction of unpaid insurance premiums from the refund, so even those in arrears are receiving benefits. Currently, offsetting is only possible if the person in arrears agrees to it.
As a result, from 2020 to last year, 1,926 high-value and long-term delinquent payers who had not paid more than 10 million won in premiums for at least 13 months received benefits from the out-of-pocket maximum policy. Their total unpaid premiums amounted to 39.03 billion won, while the total refunds they received reached 1.89 billion won.
Even among those who are not high-value delinquent payers, there are far more cases of individuals receiving refunds under the policy after not paying premiums for over a year. From 2020 to August of this year, 89,885 people fell into this category, with unpaid premiums totaling 146.99 billion won and refunds amounting to 85.28 billion won.
The National Health Insurance Service stated that a bill allowing the deduction of unpaid premiums at the time of refund is currently pending in the National Assembly, and expressed hope that its passage would help reduce the financial burden on the health insurance fund. Assemblywoman Seo emphasized, "High-value and long-term delinquent payers should not be able to enjoy these benefits without any restrictions," adding, "We will promptly amend the relevant laws in the National Assembly to address this institutional loophole."
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