현행 실손의료보험 제도의 문제점 분석과 표준약관상 보장 및 면책조항에 대한 소비자의 이해가능성 제고를 위한 연구 － 약관구성 형식과 내용의 변경을 통하여 － = A Study on Problems of Current Medical Insurance for Actual Expense and Analysis on Improvement Plan to Raise Possibility of Consumers' Understanding of Coverage and Exclusion Clauses in the General Insurance Policy

다국어 초록 (Multilingual 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.

참고문헌 (Reference)

1 "한국경제신문 2012년 7월 17일 기사 참고"

2 금융감독원, "표준형 단독 실손의료보험 판매"

3 "조선일보 2012년 6월 5일자 기사 참고"

4 "연합뉴스 2013년 2월 22일 기사"

5 "연합뉴스 2013년 2월 13일 기사 참고"

6 "연합뉴스 2012년 8월 30일 기사 참고"

7 "연합뉴스 2012년 7월 24일 기사 참고"

8 금융감독원, "실손의료보험 표준화 방안"

9 금융감독원, "실손의료보험 종합개선대책"

10 서울중앙지법, "선고 2004나21069 판결"

11 "분쟁조정 제2010-91호; 제2001-7호 결정"

12 "보험업법"

13 "보험업감독업무시행세칙"

14 "보험업감독업무시행세칙"

15 박세민, "변액보험 및 실손의료보험 약관의 소비자 이해도 제고" 생명보험협회 및 손해보험협회 2012

16 금융감독원, "갱신형 실손의료비 보험 및 정기보험 가입시 유의사항"

17 "개정 실손의료보험표준약관"

18 "개정 실손의료보험표준약관"

19 "2011년도 손해보험협회 통계자료"

20 "2011년도 보험개발원 통계자료"

21 "2011년도 국민건강보험공단 건강보험환자 진료비 실태조사"

22 "2011년도 건강보험 통계연보 참고"

23 "2010년도 국민건강보험공단 통계자료"