보험에서의「입원의 적정성」판단에 대한 고찰 - 일본과의 비교를 중심으로-

Insurance contracts have moral risks in that they pay relatively small premiums and can receive large amounts of insurance in the event of an insurance accident, and financial authorities are trying to prevent these moral risks. Nevertheless, moral risks have been realized and appear in many forms, and among them, insurance disputes related to hospitalization are representative examples of moral risks being realized. This is the case where unnecessary hospitalization is intentionally performed for the purpose of hospitalization benefits, or the purpose of large insurance payments is to be issued by listing the name of a specific disease that has not been treated in the hospitalization confirmation form. In this way, if the insured is intentionally hospitalized to receive hospitalization benefits, it seems to be evolving in the form of claiming hospitalization medical expenses even though he is not hospitalized in cooperation with medical institutions. It seems as if it is wise to consider insurance contracts as a means of financial technology and receive large amounts of insurance money. The reason why there are continuous disputes related to hospitalization can be considered in that the definition of 'hospitalization' is not clear in terms of terms and conditions. It is not easy to objectively define 'hospitalization'. The question of whether hospitalization is appropriate is continuously being discussed in Japan. In this study, we tried to analyze each type of insurance claim related to hospitalization in Korea and obtain implications for considerations and improvement measures when determining the appropriateness of hospitalization in domestic practice through comparative analysis of how Japan, which has a similar insurance system, judged the appropriateness of hospitalization. The results of the study are as follows. First, accept general medical opinions to secure objectivity and fairness. Second, it is a principle not to consider personal circumstances. Third, the issuance of hospitalization confirmation cannot be estimated as hospitalization adequacy. Fourth, the definition of hospitalization in the terms and conditions is unified, and the wording of the terms and conditions is clarified to protect the insured. Fifth, long-term hospitalization is prevented by establishing an information sharing system of medical institutions when making hospitalization decisions, and medical guidelines are prepared according to injuries. Sixth, it can be considered that the Health Insurance Review and Assessment Service entrusts the medical cost review. Finally, in the case of inpatient medical expenses, it will be possible to prevent overcharging by subdividing the compensation criteria.