Had surgery at the hospital, but insurance payout is '0 won'... Why?

A person named Mr. A, who broke part of his tooth while chewing hard food (crown fracture), received root canal treatment (periodontal resection) at a dental clinic and filed a claim for surgical insurance benefits, but the claim was denied. The insurance company stated that "root canal treatment is merely a medical procedure such as simple nerve blocking and is not eligible for surgical insurance benefits." The insurance company's position was that the surgical insurance benefits are only paid when the treatment falls within the definition of surgery specified in the policy terms.

Recently, the Financial Supervisory Service warned consumers about many cases where they are unable to receive insurance payouts despite having signed up for accident and illness insurance that covers surgery costs, diagnostic fees, and hospitalization expenses. Not all surgeries, hospitalizations, or diagnoses are covered; the payout depends on the definitions of insured events, reasons for payment or non-payment of claims, as specified in the policy terms.

First, insurance benefits for surgery costs are payable regardless of whether the term is '~surgery' or '~operation,' as long as the procedure falls under the surgical methods specified in the policy (such as cutting or excision). According to the policy, surgery refers to procedures that use medical instruments with the direct purpose of treatment, involving actions such as cutting (removing a specific part) or excision (removing a specific area). Procedures like aspiration (suction with a syringe or similar device), puncture (inserting a needle or tube to extract fluids or tissues or to inject medication), and nerve block are not considered surgeries.

The diagnosis fee insurance payout is only provided when there is sufficient evidence from test results and a confirmed diagnosis according to methods specified in the policy, such as biopsy. Please note that if the diagnosis is not confirmed through the methods outlined in the policy or if the test results for diagnosis are insufficient, it is difficult to recommend compensation.

For example, even if the primary care physician's diagnosis report states 'C code (malignant neoplasm)' indicating cancer, insurance benefits may not be payable unless the diagnosis is based on microscopic findings from tissue or blood tests. Additionally, a diagnosis of cancer must be made by a pathologist or a specialist in diagnostic laboratory medicine. This diagnosis must be based on microscopic findings from tissue biopsy, fine needle aspiration, or blood tests.

Hospitalization insurance benefits are paid only when hospitalization is for direct treatment purposes, within the limit of the payment days. The policy limits the payment days for hospitalization benefits to 180 days. From the 181st day onward, you cannot receive hospitalization insurance benefits.

Even if a patient is hospitalized more than once for the same condition or disease treatment, it is considered as one continuous hospitalization, and the total days of hospitalization are summed up. For example, if Mr. C, who was hospitalized for 180 days at Hospital B due to a fall injury causing a brain hemorrhage, is transferred to Hospital D to continue treatment for the brain hemorrhage, it would be difficult to receive hospitalization insurance benefits.

If you were hospitalized to alleviate aftereffects or boost immunity, hospital stay insurance benefits may not be paid out. This is because hospitalization insurance benefits are only provided for direct disease treatment. A Financial Supervisory Service official stated, "Whether insurance benefits are actually payable depends on the individual insurance policy and specific factual circumstances, so it is essential to check the relevant policy and details."