백내장 수술과 실손의료보험 보상한도에 관한 판례평석 ─ 법원 판례를 중심으로 ─

According to the “2023 Major Surgery Statistics Annual Report” released by the National Health Insurance Service on December 16, 2024, among 34 major surgeries in 2023, cataract surgery was performed 637,879 times, representing a decrease of approximately 13% compared to 2022. However, it still ranked as the most frequently performed surgery and the third in terms of surgical treatment costs. Additionally, according to the “2023 Health Insurance Statistical Yearbook,” cataract surgery is one of the most common inpatient surgeries. However, the average hospitalization period for cataract surgery is only 1.1 days, significantly lower than the average hospitalization period of 5.6 days for the 34 major frequent surgeries. These statistics indicate that cataract surgery is a frequently performed surgery with a high dependency on hospitalization. However, compared to other surgeries, cataract surgeries are often conducted as 'same-day admission' or 'day care' procedures. Meanwhile, it is estimated that about 80% of the entire population is subscribed to indemnity insurance, which is divided into inpatient and outpatient coverage. Inpatient coverage compensates up to 50 million KRW, while outpatient coverage is limited to 200,000 to 250,000 KRW. Although cataract multifocal lens surgery generally costs between 3 million to 5 million KRW, but the total time required, including pre- and post-operative examinations, is relatively short, typically around 2 to 3 hours. However, a problem has arisen as cases are rapidly increasing where individuals, without any special symptoms, stay in medical institutions for more than 6 hours after surgery and claim indemnity insurance based on the possibility of postoperative complications, all to meet the inpatient requirements. In 2022, the Supreme Court of Korea ruled that since the essence of treatment should correspond to inpatient treatment of 6 hours or more, it is reasonable to pay actual 2-3 hour cataract surgeries within the outpatient limit for indemnity insurance. However, even after the Supreme Court ruling, there have been lower court decisions that recognize the appropriateness of hospitalization for cases where patients stayed in hospital rooms for more than 6 hours due to the potential risk of complications, showing a divided stance among courts. This issue arises from the ambiguity and abstractness of the concept of the substantive nature of treatment. Therefore, this study compares the judicial grounds for cases where the appropriateness of hospitalization for cataract surgery was recognized with those where the appropriateness of outpatient treatment was recognized. It examines the meaning of the substantive nature of treatment, as presented as the distinguishing criterion, in light of good faith principles. Based on this examination, the study proposes an improvement plan for the insurance policy and reviews the possibility of retroactive application.