• 무역상무연구
• /
• 제65권
• /
• pp.71-94
• /
• 2015

The insurer's right to take legal proceedings in the name of the assured against a third party who has caused loss of or damage to the goods is of particular importance in marine cargo insurance under international trade transaction. The amounts recovered in subrogation actions, known in practice simply as recoveries, form a significant element in the balancing of the cargo insurer's underwriting account by improving ing the loss record. However, even if the carrier involved in the accident have a liability for damages, in some cases can not claim damages in accordance with the after clauses and carrier's exemption clauses indemnity carrier under the contract of carriage. In recent, the dispute cases to argue damages claim of the carrier in connection with business practices of surrender B/L, the claim is dismissed cases in accordance with the Arbitration Rules of the after clauses. In the future, the surrender B/L is continually to use as a marine transport method, it may also be interested in insurance subrogation of damages claims to insurance accident by a surrender B/L.

• 무역상무연구
• /
• 제50권
• /
• pp.139-161
• /
• 2011

The retroactive insurance is the system that the Assured, the principal of insurance contract shall be entitled to recover for insured(beneficiary in insurance of persons) loss during the period of insurance covered by this insurance, not withstanding that the loss had occurred before the contract of insurance concluded. The retroactive insurance is applicable to both property insurance and insurance of persons. The commercial law of Korea stipulates its rules in the insurance volume. The ultimate and definite articles of cargo insurance about the retroactive insurance are stipulated in MIA and ICC. In general insurance of persons stipulates relevant articles in the clause. Even though articles pertinent to the retroactive insurance are written explicitly in relevant law, it is difficult to settle the claim just by using specified rules of related regulations. Therefore, a claim is settled down based on the actual facts. After studying some of the actual dispute facts connected with the retroactive insurance having properties mentioned, this paper suggests controversial points and alternative ideas.

• 보험의학회지
• /
• 제27권1호
• /
• pp.33-36
• /
• 2008

BACKGROUND : The medical claims review(MCR) is unique methodology of medical consultation in terms of insurance claim administration in Korean insurance market. The most important practical matter in the MCR is formatted question. In Korea, medical specialty is composed of 26 legally defined hospital departments. It is worth of studying to investigate type of MCR by hospital departments. METHODS : Fifty Cases of the MCR were selected randomly by statistical program SPSS among 1,032 cases which were performed between April 1, 2006 and March 31 2007. All of selected cases were evaluated one insurance doctor and made a score points from 0 to 10 in terms of hospital department. RESULTS : Multidimensional scaling was performed. The MCR types - diagnosis, malignancy and cause of death are located in the same 2-dimensional configuration area. It can be called as verification of benefit. Others are advice. - such as causality, interpretation, translation, independent medical examination, and so on. DISCUSSION : We can conclude the classification of MCR typology are two main subjects, verification and advice. Theses results are same as previous article which was based on experience.

• 보건행정학회지
• /
• 제14권4호
• /
• pp.88-113
• /
• 2004

Starting from April, 2003, new pre-review system has been introduced and implemented to reduce unnecessary conflict with medical care organizations caused by current retrospective claim review system and to enhance efficiency of review system. The main purpose of pre-review system is to educate doctors to contrive adequacy of medical services. This research mainly focuses on effectiveness of pre-review system's influence on physicians' behavior changes. The analysis-participants were drawn from 1,449 clinics which implemented pre-review system, since April of 2003. The research results are as followings. First, the amount per claim has reduced by $\\3,154$, days of visit per claim by 0.1 day, and amount per visit by $\\412$, which were statistically significant. Second, anesthesiologists have decreased in three indicators the most, and the internists had least of changes. Third, the amount per claim and days of visit per claims has dropped significantly on physicians with less periods of practice and physicians with more ages. Fourth, the clinics without the expensive medical equipments, the city clinics showed significant decrease on days of visit per claim. Fifth, in intervention methods, the one-to-one education showed more significant decrease on amount per visit rather than information feedback by paper. In conclusion, the pre-review system have an impact on self-imposed physician behavioral change. The outcome of this research may be utilized for future extension implementation of pre-review system. Furthermore, it is showed that ability of transitions in medical services review system according to the future transition of payment system and context of health service policy.

• 의료법학
• /
• 제8권1호
• /
• pp.137-177
• /
• 2007

The medical expenses review system in Korea has developed under fee-for-service system with its own unique structure. The importance of reviewing medical expenses has been emphasized, as the size of medical expenditures moving through the health insurance legal context and its weight in the national economy have increased very rapidly. It is, however, analyzed that the feuds and arguments continue among the stakeholders for the lack of laws supporting the medical expenses review system. The medical expenses review is a series of administrative procedures, deciding whether claims from medical care institutions to the insurer are legal and valid or not. It mainly controls the increase of unnecessarily excessive health insurance claim and prevents fraudulent claim and abuse and checks the less use or unsuitable use of medical resources. It also works a function guarantees medical benefits for the appropriate treatment according to the object of health insurance system as a social insurance scheme. The dispute on legal base of the medical expenses review is about the source of law in the medical expenses review. There are the Health Insurance Act and administrative laws as jus scriptum and the guidelines of review as administrative orders. The medical expenses review should reflect various factors, such as the development of medical healthcare technologies, the health expenditures distribution, the financial situation of the health insurance, and the evaluation on the level of appropriate benefits. It is also likely to adapt to the traits of characters of medicine, and trends and transition, Besides it should judge the legality and the validity of medical benefits expenditures by synthesizing these all factors. And the evaluation system of appropriateness of medical benefits was administrative procedure which was consecutive with reviewing the medical expenses system and it was intended to make up for the result of reviewing the medical expenses in more comprehensive levels.

• 대한임상약리학회:학술대회논문집
• /
• 대한임상약리학회 2003년도 춘계 Symposioum
• /
• pp.25-25
• /
• 2003

• 무역상무연구
• /
• 제76권
• /
• pp.125-145
• /
• 2017

Where an insurer has unreasonably refused to pay a claim or paid it after unreasonably delay, the existing law in England does not provide a remedy for the insured. Accordingly, the insured is not entitled to damages for any loss suffered as a result of the insurer's unreasonable delay. This legal position differs from the law in Scotland and most major common law jurisdictions. LC thought that the legal position in England is anomalous and out of step with general contractual principles. LC considered that a policyholder should have a remedy where an insurer has acted unreasonably in delaying or refusing payment of claim, and, therefore, recommended a statutory implied term in every insurance that the insurer will pay sums due within a reasonable time and breach of that term should give rise to contractual remedies, including damages. More detailed recommendations of LC are as followings. First, it should be an implied term of every insurance contract that, where an insured makes a claim under the contract, the insurer must pay sums due within a reasonable time. Secondly, a reasonable time should always include a reasonable time for investigating and assessing a claim. Although a reasonable time will depend on all the relevant circumstances, for example, the following things may need to be taken into account, that is, (1) the type of insurance, (2) the size and complexity of the claim, (3) compliance with any relevant statutory rules or guidance, and (4) factors outside the insurer's control. Thirdly, if the insurer can show that it had reasonable grounds for disputing the claim(whether as to pay or not, or the amount payable), the insurer does not breach the obligation to pay within a reasonable time merely by failing to pay the claim while the dispute is continuing. In those circumstances, the conduct of the insurer in handling the dispute may be a relevant factor in deciding whether the obligation was breached and, if so, when. Fourthly, Normal contractual remedies for breach of contract should be available for breach of the implied term to pay sums due within a reasonable time. Finally, In non-consumer insurance contracts, the insurer should be permitted to exclude or limit its liability for breach of the obligation to pay sums due within a reasonable time, unless such breach was deliberate or reckless, and such an insurer's right to contract out will be subject to satisfying the transparency requirements.

• 보험의학회지
• /
• 제29권2호
• /
• pp.33-35
• /
• 2010

Multiple myeloma is characterized by the neoplastic proliferation of a single clone of plasma cells producing a monoclonal immunoglobulin and it is frequently associated with primary amyloidosis. I experienced a medical claims review case of plasma cell dyscrasia with primary amyloidosis. This medical consulting work to insurance claims will be helpful for another similar claims administration.

• 보건행정학회지
• /
• 제26권1호
• /
• pp.71-78
• /
• 2016

The value of using health insurance claim database is continuously rising in healthcare research. In studies where comorbidities act as a confounder, comorbidity adjustment holds importance. Yet researchers are faced with a myriad of options without sufficient information on how to appropriately adjust comorbidity. The purpose of this study is to assist in selecting an appropriate index, look back period, and data range for comorbidity adjustment. No consensus has been formed regarding the appropriate index, look back period and data range in comorbidity adjustment. This study recommends the Charlson comorbidity index be selected when predicting the outcome such as mortality, and the Elixhauser's comorbidity measures be selected when analyzing the relations between various comorbidities and outcomes. A longer look back period and inclusion of all diagnoses of both inpatient and outpatient data led to increased prevalence of comorbidities, but contributed little to model performance. Limited data range, such as the inclusion of primary diagnoses only, may complement limitations of the health insurance claim database, but could miss important comorbidities. This study suggests that all diagnoses of both inpatients and outpatients data, excluding rule-out diagnosis, be observed for at least 1 year look back period prior to the index date. The comorbidity index, look back period, and data range must be considered for comorbidity adjustment. To provide better guidance to researchers, follow-up studies should be conducted using the three factors based on specific diseases and surgeries.

• 한국임상약학회지
• /
• 제22권4호
• /
• pp.291-303
• /
• 2012

As respiratory tract infections (RTI) account for about 60% of all antibiotic prescriptions in outpatient care setting, there are significant concerns about emerging resistance that are largely due to the excessive or inappropriate use of antibacterial agents for viral respiratory infections. This study was aimed to develop retrospective drug utilization review (DUR) program of antibiotics for RTIs using Delphi methods. Retrospective DUR criteria of antibiotics for RTIs were identified based on clinical practice guidelines and opinion of experts. Expert panel members were clinical doctors and pharmacists and Delphi method was applied by survey on 16 members of panels. The claim data from Korean Health Insurance Review & Assessment (HIRA) were used to examine trends in outpatient antibiotic prescription between Janunary to December of 2008. As results, Quality index for RTI was assessed for the claim type, antibiotics use of quantity, duration, number and cost. Antibiotic prescription rate for RTIs, Defined Daily Dose (DDD), and duration of antibiotics use were more recognized as significant quality index by experts' opinion. Use of first line agents suggested by guidelines was low and duration of antibiotics use was shorter compared to the recommendations. Antibiotics were over prescribed for RITs. However, dose and duration of antibiotics were under-used.