허위⋅과잉진료 관련 실손의료보험 인수⋅지급심사 개선방안 및 감독행정 연구

There may be a variety of causes that lead to an increase in the loss ratio of indemnity medical insurance, but false or excessive medical treatment is consistently pointed out as the main cause. However, previous studies abstractly discuss improvement measures from the perspective of the adequacy of indemnity medical insurance payments. Therefore, based on the specific causes of false and excessive medical treatment, it is necessary to seek ways to improve the indemnity medical insurance system from the perspective of insurance contract underwriting, insurance payment review, and supervisory administration. First, it is possible to consider a plan to reduce the incentive for false or excessive treatment by ensuring that costs for false or excessive treatment are not paid through review by a professional review body. In this regard, the establishment of not-covered service review standards should take precedence. Next, if there are concerns about insurance fraud at the stage of underwriting an insurance contract, insurance fraud can be prevented by refusing the underwriting. In this regard, there is a need to revise the law to enable inquiries into insurance subscription status and insurance fraud history. In addition, in terms of insurance supervision administration, in relation to insurance contract underwriting, insurance payment review, etc., the supervisory authority’s proactive preventive administration, such as the establishment of payment review guidelines for the insurance industry and dispute response principles, is needed. Also, there is a need to reorganize the system in a way to increase the effectiveness of supervisory administration, such as improving the regulations on the obligation to prevent excessive medical treatment in indemnity medical insurance and canceling registration and restricting registration qualifications for insurance planners who have been found guilty of insurance fraud. I hope that the results of this study call attention to the need for system improvement measures related to the underwriting and payment review of indemnity medical insurance and supervisory administrators, and provide practical help in preparing system improvement measures by presenting preconditions and specific considerations for system improvement.