Refusal of insurance payment for ‘laser treatment and procedures’… Law: “Surgery is required if the body is manipulated”

Let’s claim the cost of laser treatment for ‘congenital nevi’… Insurance company “Simple procedure without incision”
The court said, “Laser removes lesions by destroying melanin cells… It is practically similar to excision.”

The court ruled that even if it is a laser procedure rather than a surgical operation, if it has a practical surgical effect, such as removing a lesion, it should be recognized as surgery under the terms and conditions.

According to the legal community on the 5th, the 3-1 Civil Affairs Division of the Suwon District Court upheld the original court ruling that ruled in favor of the plaintiff in the appeal trial of an insurance claim lawsuit filed by A, a woman in her 40s, against the insurance company on the 15th of last month.

Mr. A signed an insurance contract in which his children, who are scheduled to be born in 2019, are insured. The contract included a special clause providing for payment of surgical expenses for congenital deformities, deformities, and chromosomal abnormalities.

Mr. A's child, born the following year, was diagnosed with a congenital non-neoplastic nevi and received laser treatment accordingly. Initially, the insurance company paid the treatment costs, but later refused to pay for additional treatment costs, resulting in a dispute.

Mr. A filed a lawsuit against the company, claiming that he received a definitive diagnosis from a doctor and met all requirements for insurance payment, including receiving the surgery necessary for treatment.

On the other hand, the insurance company refuted this. This means that the diagnosis cannot be considered confirmed based solely on clinical estimates without undergoing a biopsy. In addition, it was argued that laser treatment is not subject to payment under the terms and conditions because it is a non-surgical procedure that involves manipulation such as cutting or resection of the body.

The court ruled in Mr. A’s favor. The court explained, “The doctor in charge expressed his opinion that the diagnosis of the disease is mainly confirmed through clinical observation by a specialist,” and “The diagnosis of the disease should be considered confirmed.”

Regarding the question of whether or not surgery was an issue, he said, "The disease is unlikely to improve naturally and may affect social life, so treatment is necessary. The laser procedure used in the treatment is a method of treating lesions by breaking down melanin pigment cells."

He added, “This can be seen as similar to excision in that it involves manipulating the living body to remove the lesion, so it is a surgery as stipulated in the terms and conditions.”

The insurance company, dissatisfied with the results of the first trial, appealed, claiming that the case did not require treatment, but the second trial court also made the same ruling.

Attorney Choi Han-sik of Daeryun Law Firm, who represented Mr. A, explained, "There was a situation where the definition of surgery in the terms and conditions was limited to amputation or excision of a living body, but we were able to obtain a favorable ruling by emphasizing that laser treatment actually has a similar effect to excision."
 

Reporter Seohyun Lee sunshine@kyeonggi.com

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Insurance payment refusal for 'laser treatment, procedure'... Law: “Surgery is required if the body is tampered with” (Shortcut)