보험약관에서 정한 ‘입원’의 적정성 판단과 관련된 쟁점 고찰 -일본에서의 논의를 통해 본 시사점-

In the claim adjust’s practice, there are frequent disputes regarding the appropriateness of hospitalization in relation to the payment of inpatient insurance money under the insurance policy. A typical case is whether to pay inpatient insurance money (per day of hospitalization) for the insured in relation to the judgment about the appropriate length of hospitalization and in determining whether the conditions of hospitalization prescribed in the policy are met, it is a matter of which priorities should be placed if the opinions of the doctor and the agencies that have assessed the adequacy of hospitalizations conflict. In the case of Japan, when determining whether to meet the ‘definitions of admission’ requirement, given the medical level at the time of hospitalization, the symptoms are difficult to treat at home and elsewhere, they interpret that it is only reasonable to determine that care is needed in a medical institution. If the doctor's judgment is fully followed, the substantiality or necessity of hospitalization may depend on the doctor's insight or subjective judgment, resulting in an unreasonable imbalance among the insured. It is the position of Japan's majority and judgmental attitude to interpret that the medical level at the time of hospitalization takes precedence over the opinion of the doctor. On the other hand, the Korean court's decision gives priority to the opinion of the doctor who directly treated the patient rather than the outcome of the post-examination, acknowledging the necessity and appropriateness of hospitalization. This position creates a lot of problems. Although doctors can make a fair and objective judgment as experts, on the one hand, they are in a position to be paid for care, it is also possible to conspire with patients for unnecessary hospitalizations. To remedy these problems, it is necessary to improve the terms and conditions and insurance policies first, to establish detailed hospitalization criteria for minor diseases and injuries. And in the case of admission special terms and conditions, there is a need to limit double insurance. As a future task, it would be better to come up with a more reasonable alternative through a thorough investigation into the aptitude of ‘admission’ to avoid any moral risk related to inpatient insurance money.