현행 실손의료보험 제도의 문제점 분석과 표준약관상 보장 및 면책조항에 대한 소비자의 이해가능성 제고를 위한 연구 － 약관구성 형식과 내용의 변경을 통하여 －

Abstract

In the situation that only 63% of amount for medical expenses is borne by the national health insurance. public insurance, almost half the number of people have currently taken up health insurance policy for actual loss and damage, a private insurance product and it is expected that, even in the future, the demand for such product will continuously increase. However, current system of health insurance for actual loss and damage shows a lot of problems: from the perspective of consumers, wide range of increase of insurance premium dissatisfies; and, even from the perspective of insurance companies, their loss ratio has consistently increased as the amount of insurance to be paid has rapidly increased. It can be said that the important reasons for the problems of current system of health insurance for actual loss and damage are: excessive use of medical institutions by consumers insured by health insurance for actual loss and damage; excessive medical treatment of medical institutions to such consumers; and non-payment items of medical treatment and non-existence of control over the cost for such items under the National Health Insurance Act. In addition, in light of its easiness, conciseness and clarity, current standardized contract of medical insurance for actual loss and damage has lots of problems. From consumers' point of view, the pages of such contract are too numerous. The reason is that, in the standardized contract, the insured items are classified into injuries and diseases, respectively, and thereafter, medical costs for both inpatient and outpatient is respectively divided for each items. After then, all the sub-items of inpatient and outpatient to be covered and not covered by insurance are respectively set forth. In order to decrease the quantity of the standardized contract, the insured items to be classified must be changed into inpatient and outpatient and then, it is necessary to set forth the contents of insurance coverage and grounds for exemption from responsibility which can be commonly applicable. After then, the matters to be individually applied should be separated and prescribed in the items subject to such application. By doing this way, considerable quantity of the standardized contract will diminish. The languages of current standardized contract are not so clear that there is possibility of dispute regarding the construction of contract and, thus, in order to enhance consumers understanding, it is necessary to move several provisions of the contract into other parts of the contract. Given its importance and popularity, the contents of standardized contract of health insurance for actual loss and damage should be continuously amended from now on and the direction of such amendment must be for enhancing its easiness, conciseness and clarity.