A Twist While Claiming Insurance on Behalf of Father Who Suffered a Stroke... Unexpected Requirement

Financial Supervisory Service Releases Cases on Insurance Benefit Payments, Claims, and Premium Surcharges
Check for On-Premises Medical Expense Rider in Facility Owner and Manager Liability Insurance
Premium Surcharge Applies Even If Spouse Cau

Mr. A's child was diagnosed with developmental delay due to a brain disorder and received language and neurodevelopmental intervention therapy. During this process, the child was diagnosed with a permanent impairment related to speech function. Mr. A filed a claim for disability insurance benefits through a children's insurance policy, but the insurer refused payment. The insurer argued that since the child was able to pronounce some consonants among the four types of speech sounds-bilabial, alveolar, palatal, and laryngeal-it was difficult to consider the condition as a "permanent" impairment.

However, the Financial Supervisory Service determined that if even some consonants within a speech sound category cannot be pronounced, it should be considered that the entire speech sound cannot be pronounced. For example, if the child cannot pronounce 'm' and 'b' among the bilabial sounds 'm', 'b', and 'p', but can pronounce 'p', it should still be interpreted as an inability to pronounce bilabial sounds. Taking into account the fact that Mr. A's child was diagnosed with a disability after a long period of treatment and the results of various tests, the Financial Supervisory Service concluded that a permanent impairment existed and ordered the insurer to pay the insurance benefits.

The Financial Supervisory Service disclosed cases of complaints related to insurance claim payments, claims, and premium surcharges. Getty Images

On January 14, the Financial Supervisory Service released major complaint cases and its decisions regarding insurance claim payments, claims, and premium surcharges that occurred in the third quarter of last year.

Mr. B suffered a fall accident while using a golf practice facility inside an apartment complex and filed a claim for accident insurance benefits with the liability insurer. The apartment residents' representative council, as the policyholder, had purchased facility owner and operator liability insurance and additionally subscribed to a special rider for on-premises medical expenses. This rider compensates for medical expenses within certain limits if a third party is injured in an accident on the premises, even if there is no defect in the facility. However, the insurer argued that since there was no defect in the facility during the accident, the residents' representative council had no liability, making it difficult to pay the insurance benefits. Mr. B then filed a dispute resolution request with the Financial Supervisory Service, claiming that the denial of insurance benefits was unfair, and the Financial Supervisory Service ruled in favor of Mr. B.

Facility owner and operator liability insurance is designed to cover the liability that the insured is responsible for. If the insured has no legal liability, insurance benefits may not be paid to the victim. However, the on-premises medical expenses rider allows the victim to claim actual medical expenses from the insurer if an accident is confirmed to have occurred within the facility, even if the insured (the residents' representative council) does not have liability.

Mr. C, when purchasing automobile insurance, added a limited driver rider that allowed his spouse to drive as well. This rider enables not only the car owner but also the spouse and family members to be covered as drivers. Mr. C's spouse caused an accident while driving Mr. C's car. Subsequently, Mr. C was notified by the insurer of a premium surcharge. Mr. C filed a dispute resolution request with the Financial Supervisory Service, arguing that it was unfair for the premium surcharge to be applied to him, the insured, rather than the spouse who actually caused the accident.

The Financial Supervisory Service did not accept Mr. C's claim. Automobile insurance calculates discounts and surcharges based on the insured, not the actual driver involved in the accident. Therefore, the insurer's handling of the premium surcharge applied to Mr. C, the insured, even though his spouse caused the accident, was not considered unfair.

Mr. D, whose father was both the insured and the insurance beneficiary, filed a claim for critical illness insurance benefits on behalf of his father, who had lost consciousness due to acute stroke. The insurer refused payment, stating that only the father, as the beneficiary, could file the claim, and no one else could do so on his behalf. Mr. D then filed a dispute resolution request with the Financial Supervisory Service.

The Financial Supervisory Service determined that, under civil law, unless a person is a legal representative or adult guardian, it is not possible to perform legal acts such as filing insurance claims on behalf of another. Even if Mr. D is an immediate family member of the insured, he cannot file a claim on behalf of his father unless he has been delegated the right to exercise the claim or appointed as an adult guardian. However, by utilizing the "designated representative claim system," if the insured is unable to file a claim due to a serious illness, the spouse or children of the insured may file a claim on their behalf.