Insurers denied payouts in 85.8 percent of all insurance-related damage relief filings received last year, according to an analysis by the Korea Consumer Agency.
According to the agency on Monday, insurance-related damage relief filings have continued to rise each year, totaling 756 in 2021, 829 in 2022, 1,067 in 2023, 978 in 2024, and 930 last year. However, cases in which insurers refused to recognize treatments or demanded medical consultations to reject payouts have increased in tandem.
Of the 930 insurance-related damage relief filings received by the agency last year, 85.8 percent (798 cases) arose from insurers refusing to pay benefits. The most common reason for denying payouts was "non-recognition of the attending physician's diagnosis or treatment," accounting for 67.4 percent (538 cases). This was followed by "disagreement over policy terms" at 20.7 percent (165 cases) and "disagreement over loss amounts" at 9.0 percent (72 cases).
Of the 538 cases in which insurers did not recognize the attending physician's diagnosis or treatment, 70.1 percent (377 cases) occurred because consumers did not agree to the insurer's demand for a medical consultation or did not accept the medical consultation results.
There were also substantial cases in which insurers refused to recognize diagnoses by doctors affiliated with general hospitals. Of the 377 cases in which insurers demanded medical consultations and rejected payouts, 38.5 percent (145 cases) involved patients whose attending physicians were affiliated with "general hospital-level" institutions, including university hospitals. In addition, "hospital-level" cases accounted for 31.3 percent (118 cases), and "clinic-level" cases accounted for 30.2 percent (114 cases).
The insurance payouts that insurers denied citing medical consultations averaged 16.18 million won. By amount, the "1,000 million won or more but less than 30 million won" range was the most common at 39.1 percent.
According to the agency, the General Insurance Association and the Life Insurance Association established and have operated "medical consultation internal control standards" since August 2021 to prevent medical consultations from being abused as a means of denying insurance payouts. However, improvement is needed because there are effectively no restrictions on the targets subject to medical consultation.
"Based on this analysis, we plan to ask the General Insurance Association and the Life Insurance Association to improve the 'medical consultation internal control standards' to prevent consumer harm caused by insurers' unnecessary medical consultation demands," the agency said.
The agency urged consumers to check in advance their insurer's payout review criteria when undergoing high-cost non-covered treatments; to request a detailed explanation of the reason for the medical consultation and the contents of the inquiry when an insurer demands one; and to request a re-examination if they object to the medical consultation results.
