보험약관상 입원비 지급요건 해당성과 관련된 쟁점 고찰-일본에서의 논의를 중심으로-

Abstract

In insurance practice between Japan and Korea, there are many disputes related to the payment of hospitalization insurance money. In Japan, a number of precedents and majority theories say, “in addition to the diagnosis of the doctor, hospitalization insurance money is paid only objectively and reasonably necessary hospitalization from the medical level and common sense at the time of hospitalization”. On the other hand, in the case of our court, the opinion of the doctor is prioritized over the medical judgment at the time of hospitalization. In this paper, precedents on the appropriateness of hospitalization requirements and theories were examined in Japan. In addition, we reviewed the implications of these discussions in Japan for our insurance practice, and the conclusions are as follows. First, it is necessary to strictly interpret the requirement in the clauses that “he insured (patient) is hospitalized and always devoted to treatment under the care of a doctor.” It should be judged from the viewpoint of the hospitalization is not simply based on the doctor’s judgment, but there is objective rationality in the doctor’s judgment and whether treatment at home is difficult is objectively recognized. Next, in order to prevent unnecessary long-term repeated hospitalization for the purpose of receiving hospitalization insurance money even though outpatient treatment is possible, I propose to improve clauses and establish detailed hospitalization standards for minor diseases and injuries. Furthermore, when the insured claims hospitalization insurance money, it is not enough just to submit the doctor’s hospitalization certificate, and I think it is reasonable for the insured to claim hospitalization insurance money with more specific and detailed evidence. In other words, the doctor must prove that the form of ‘hospitalization’ is essential for medical treatment conducted during the treatment period. To this end, I think the most reasonable way to judge the necessity and appropriateness of the insured’s hospitalization is through the decision of the ‘Health Insurance Review and Assessment Service’.