Insurance Company’s Demand for Cost Return Due to Alleged Over-treatment: Response Strategies
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A patient (policyholder) who received inpatient treatment at a Korean medicine medical institution filed a claim for hospitalization insurance benefits with the insurance company. The insurance company, citing the long duration of the patient's hospitalization, judged that the medical institution had over-treated the patient. The insurance company argued that the medical institution should return a substantial portion of the insurance benefits paid to the patient, either as compensation for damages or because the length of the hospitalization was deemed excessive, and filed a lawsuit against the medical institution.
Key Issues in the Legal Dispute
In this case, the legal dispute revolves around whether it was necessary to admit the patient to the hospital, whether outpatient treatment could have been sufficient, and whether the hospitalization period was excessively long. In court, the medical institution argues that the decision regarding hospitalization and the appropriateness of the hospitalization period is a matter to be judged by the treating medical professionals, not by the insurance company, which is not an expert in medical practice.
The Insurance Company’s Perspective
The insurance company, after analyzing the insurance claim data and reviewing assessments and analyses from their medical professionals, contends that the patient could have received outpatient treatment at home and the hospital. They argue that the hospitalization period is excessively long given the diagnosis. These types of cases, involving not just insurance companies but also health insurance agencies, can lead to investigations for potential insurance fraud or other legal violations.
Hospitals Targeted by Insurance Claims
Hospitals with a high number of inpatient rooms, a significant number of hospitalized patients, and frequent insurance claims related to patient hospitalization are often targeted by insurance companies. Additionally, hospitals where the length of hospitalization exceeds the typical duration for the given diagnosis are also likely to be scrutinized.
Challenges Faced by Hospital Operators
Hospital operators face challenges from admission brokers and patients who demand hospitalization. In some cases, patients leave the hospital without proper admission and commute from home or work, leading to the discovery of fraudulent hospitalization during investigations when CCTV footage is reviewed.
Recent Court Rulings
A recent ruling by the Seoul Central District Court sheds light on the issue. The court ruled that the Korea Institute of Korean Medicine (KIKM) acknowledged the need for inpatient treatment in this case, but there was insufficient objective evidence to conclude that outpatient treatment was impossible. The court noted that the decision to admit the patient was based on the physician's judgment, considering the severity of the patient’s condition and other factors. Therefore, the court found no reason to dismiss the judgment of the medical professionals. The judgment emphasized that the necessity and appropriateness of hospitalization should be respected unless there are special circumstances that make it unreasonable to trust the medical professionals' judgment.
Detailed Record Keeping of Treatment
However, in cases like this, it is essential for the medical institution to provide detailed records of whether hospitalization was necessary, whether outpatient treatment could have sufficed, the treatment provided during the hospitalization, and the patient's health status after treatment. Such records are critical for defending against insurance claims and potential legal challenges.
Dealing with Fraudulent Claims and Brokers
As previously mentioned, patients may seek hospitalization for reasons such as insurance claims or sick leave compensation, even when hospitalization is unnecessary. Brokers may also tempt patients into unnecessary admissions. Hospitals must be vigilant against such practices, especially if patients attempt to secretly leave the hospital during their stay. In some cases, patients may switch hospitals and repeatedly undergo unnecessary hospitalization. Hospitals must have effective measures in place to deal with fraudulent claims and brokers, as involvement in insurance fraud could lead to severe consequences, including license revocation.
Establishing Internal Standards and Monitoring Hospital Admissions
It is necessary for Korean medicine associations to establish appropriate internal standards for hospitalization periods and admission criteria. Additionally, in cases of fraudulent hospitalization, the Korean Medicine Association should encourage courts to actively request factual investigations and expert assessments. Furthermore, hospitals should ensure proper management of inpatient rooms to prevent incidents such as theft, assault, arson, or fire, which could lead to both civil and criminal liabilities.
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