[비즈한국] The 5th generation private health insurance policy is set to be launched at the end of this year. The 5th generation focuses on providing appropriate coverage primarily for universal medical expenses (covered medical expenses) and patients with severe illnesses. In particular, for "non-severe non-covered" treatments, where insurance payouts have been continuously expanding, certain items—including musculoskeletal treatments such as manual therapy and non-covered injections—will be excluded from insurance coverage. While the insurance industry is busy preparing for these new products, clinics continue to foster an atmosphere that encourages "medical shopping" amounting to millions of won. This persists because the plan to offer contract buybacks for 1st and early 2nd-generation policyholders—the hotbeds of "overtreatment"—has become optional, leaving them without any sanctions.
"Skin Laser + IV Drip" Procedures for 20,000 Won
Clinic A in Gangnam, Seoul, is known among local residents as a place where you can receive dermatological (beauty) treatments and IV drips at low prices. For just over 20,000 won per session, patients can get customized laser treatments and IV drips. Initially, the clinic was frequented mainly by women in their 40s and 50s, but as they began bringing their children, it's now common to see middle and high school students filling the treatment rooms on weekends. It is said that booking a first-time consultation takes nearly a month.
Clinic A requires patients to pay 2 million won upfront for 10 sessions, matching the maximum insurance claim limit of 200,000 won per visit. Every time a patient visits, the clinic issues a medical confirmation certificate and a detailed statement of medical expenses. The claimed amount is around 210,000 won, combining the IV drip (non-covered) and consultation fees (covered). While the type of IV drip varies, they are billed so that the total hits 200,000 won. According to user B, who visits this clinic, on one day a 20ml Hisopagen-C injection, known as a "licorice injection," is billed as 200,000 won, while on another day, the same injection is listed as 50,000 won, with other injections itemized at 100,000 won and 50,000 won, respectively.
The diagnosis listed on the medical confirmation certificate is based on blood tests conducted on the first day. The tests are free, and after diagnosing skin conditions, medical staff consult with the patient on how to structure future treatments. While the diagnosis varies by patient, "unspecified vitamin D deficiency," "unspecified gastritis," and "allergic urticaria" are the most common. Treatments are then administered based on the daily condition of the patient, following the test results.
User B, who visited on the recommendation of a neighbor, said, "They do laser treatments depending on my skin condition while I get the IV drip, so there's no reason not to come. However, the clinic doesn't tell you to sign up for another program once the current one ends because they could get caught if the patient keeps making claims." B, a 1st-generation insurance policyholder, was reimbursed 194,500 won out of a total cost of 215,090 won.
Clinics and Patients Alike Unconcerned About the Shift to 5th Generation
Clinic B, another facility in Gangnam, has become famous for offering free Personal Training (PT) and Pilates sessions. Similar to Clinic A, the programs are designed to match the 200,000-won maximum claim limit per visit. Depending on the number of manual therapy sessions purchased, patients can choose to receive exercise sessions like PT or Pilates. Payment is accepted starting from 10 sessions, and it is said that if you pay for 10 sessions of manual therapy, you can receive "10 sessions plus alpha" of PT or Pilates. Exercise equipment can be used at any time, just like in a regular gym.
C, a woman in her 50s, explained, "My purpose was PT classes rather than rehabilitation in the first place. I came here after hearing that one-on-one PT is free. I only had slight pain in my shoulder and no underlying illnesses, but I was introduced to the program after getting X-rays and consulting with the medical staff." C paid 5 million won upfront for 25 sessions. She mentioned that since she came on a recommendation, they added about 30 exercise sessions, which is more than other patients receive. C added, "I was worried about whether I would be able to get the insurance payout, but the clinic told me, 'If we take an X-ray, we’re all patients.'"
Although the 5th generation private health insurance is set to launch at the end of this year, both patients and medical staff seem unconcerned. While authorities have finalized that the new insurance policies will exclude coverage for musculoskeletal treatments like "manual therapy" and non-covered injections under non-severe non-covered items (Special Contract 2), it has no impact on 1st and early 2nd-generation policyholders who have already been receiving insurance payments without such restrictions. As the primary axis of "medical shopping," these individuals are unlikely to switch to the 5th generation policy as long as they face no burden in insurance premiums.
Initially, at a policy discussion in January, a plan was proposed to apply changes to the terms and conditions through legal amendments for a total of 16 million 1st and early 2nd-generation policies, where the revised terms could not otherwise be applied until the contract expired. However, it faced controversy over "forced conversion," and it was concluded that the contract buyback would be implemented only after observing the effects of other insurance reform measures. The authorities plan to announce the implementation plan for contract buybacks in the second half of this year after further discussions with the insurance industry.