실손의료보험에서 백내장 수술 진료비의 보상책임에 관한 판례 평석

Abstract

Cataract is a disease in which the lens becomes cloudy due to aging and causes loss of vision. It is treated with surgery to remove the cloudy lens and insert an artificial lens. There are single vision lenses and multifocal lenses as types of intraocular lenses, which are the treatment materials used at this time. Monofocal lenses have the disadvantage of requiring separate corrective glasses for near vision even after insertion, but they are inexpensive and require medical treatment under the National Health Insurance Act. On the other hand, multifocal lenses have the advantage of correcting both near and far vision, but they are expensive and do not qualify for medical care benefits under the National Health Insurance Act.
 In this case, while the state determines the price of the salary, the non-insurance price is set by the medical institution, so the medical institution has an incentive to make a profit by arbitrarily setting the cost of treatment for non-insured items. In particular, in the case of non-insured items covered by medical insurance for indemnity insurance, the patient can claim most of the medical expenses from the insurance company as insurance money. There may be cases in which overpayment or overtreatment may occur.
 In relation to cataract surgery, some eye clinics, mainly in the Gangnam area of Seoul, arbitrarily adjust the cost of examination or multifocal lenses, which are representative non-covered items, according to changes in the health insurance benefit system or medical insurance policy, without reasonable standards. It is confirmed that they are taking advantage of the business by misusing them. For example, in September 2020, when health insurance was applied to the examination fee, it was no longer possible to claim high medical expenses for the examination fee. Excessive indemnity payments are being made in the medical insurance for loss by processing hospitalization and issuing a confirmation of hospitalization, and the damage is being passed on to good medical consumers and insurance organizations.
 However, in the recent judgment of 2021 na 2013354 of the Seoul High Court on January 20, 2022, the scope of claims for medical insurance for medical loss for insured persons who underwent cataract surgery was limited to the amount of out-of-patient insurance, not hospitalization. Based on the Supreme Court’s general definition, it was emphasized that ‘the substance of hospitalization’ should be provided in addition to the standards of the Ministry of Health and Welfare notification. He also pointed out that the fact that the comprehensive fee-for-service system is applied in cataract surgery is completely different from judging whether or not the patients were actually ‘hospitalized’.
 As such, it can be said that the above judgment on the criteria for ‘hospitalization’ for cataract surgery is not limited to the clinic in this case, but is also applied to general ophthalmology clinics performing cataract surgery. Although there is regret in the interpretation of the terms and conditions related to the exemption, I hope that the judgment of the subject judgment regarding hospitalization will be an opportunity to suppress unnecessary and reckless cataract surgery.
 It seems to be a very desirable direction for government ministries, financial supervisory authorities, and the industry to take an interest in the recent cataract surgery and other problems of the surge in medical expenses and to make various efforts and attempts. As a member of society, the court also expects effective and rational judgments that can effectively suppress turmoil in the medical market and protect the rights and interests of good medical care and insurance consumers.