• 한국응급구조학회지
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• 제26권1호
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• pp.119-127
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• 2022

Purpose: This study aimed to examine the necessity of administrative compensation insurance and claims cases during the emergency medical service process among administrative compensation insurance cases and suggests problems and improvement measures. Methods: We compared the details of administrative compensation insurance claims of 15 cities and provinces, excluding Seoul and Kwangju, from 2017 to 2020 by requesting details disclosure of the comprehensive deduction for administrative compensation in 17 cities and provinces across the country. Results: A total of 69 cases were compensated through the administrative comprehensive compensation deductions. There were 53 cases of damage that occurred at the field stage, 14 cases at the transfer and hospital stage, and two other cases. Conclusion: The 119 paramedics, which are the perpetrators, should be active in field activities and free from the psychological pressure caused by increased workload and litigation. Active compensation administration is required for damage cases occurring in the firefighting activities context.

• 한방안이비인후피부과학회지
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• 제34권2호
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• pp.21-37
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• 2021

Objectives : Allergic rhinitis(AR) is a common chronic disease that accounts for 10-40% of the world's population. This study aims to analyze the status of claims, prevalence, and medical utilization of allergic rhinitis patients using representative patients sample data. Methods : This study used the National Patients Sample(HIRA-NPS) of the Health Insurance Review and Assessment Service for 7 years(2010-2016). And we defined AR patients as all statements including J30 or a subcategory of J30 as the main disease, using the Korean Standard Classification of Diseases(KCD-7). The trend of AR patients by year was divided into Western medicine(WM) and Korean medicine(KM), and analyzed by subgroup analysis such as inpatient/outpatient, gender, age, insurance type, and care institution. Results : Patients with AR were mainly claimed for first sub diagnosis in WM and major diagnosis in KM, and the number of claims increased about 1.3 times and 1.4 times compared to 2010 in WM and KM, respectively. In addition, the total annual medical expenses in 2016 increased 1.3 times and 1.7 times compared to 2010, respectively. Conclusions : Both WM and KM are showing a steadily increasing trend in medical use due to allergic rhinitis. Further research is needed by considering genetic and environmental factors and individual characteristics, and linking with additional data.

• 보건행정학회지
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• 제19권3호
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• pp.92-108
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• 2009

This study suggests a model for continuing and comprehensive management of hypertension or Type 2 diabetes mellitus (T2DM) in Korea. Moreover, this paper computed the contribution cost of hypertension or T2DM management using the healthcare medical cost, which could have occurred from stroke, myocardial infarction (MI), and end-stage renal disease (ESRD) that were successfully prevented from the effective hypertension or T2DM management. Additionally, these costs were compared with the cost of implementing the hypertension or T2DM management model suggested in this study. This study used the medical fee summary of the health insurance claims submitted to National Health Insurance Corporation by medical facilities for services provided during the period from January 1st 1999 to December 31st 2006. The prevalence rate with treatment referred to cases in which patients submitted their medical claims at least once during the period, along with an accordant diagnosis. The incidence rate with treatment referred to cases in which patients who never submitted claims for the accordant disease during the five years from 1999 to 2003 submitted claims for the accordant disease in 2004 and 2005. The relative risk of the occurrence of stroke, MI and ESRD was 11.0, 13.6, and 30.3, respectively. The attributable risk of hypertension or T2DM for stroke was 0.730, and that for MI and ESRD were 0.773 and 0.888, respectively. Based on these, the contribution cost of hypertension or T2DM is estimated to be 986.3 billion Korean Won(KRW) for stroke patients, 330.5 billion KRW for MI patients, and 561.7 billion KRW for ESRD patients as in 2005. Hence, the total contribution cost of hypertension or T2DM to stroke, MI, and ESRD is 1.878 trillion KRW. The estimate for operational costs included an annual expenditure of 50,000 KRW per each recipient and an annual subsidy of 0.22 million KRW per person for the 1.6 million low.income individuals with hypertension or T2DM to cover their out.of.pocket medical expenses. Under this assumption, it took approximately 0.6 trillion KRW to manage 5 million high.risk patients in the low. and mid.income range, coverings up to 50% of costs. In conclusion, considering the potential benefits of preventing stroke, MI, and ESRD, the costs seems to be reasonable.

• 한국기후변화학회지
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• 제8권2호
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• pp.153-161
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• 2017

The purpose of this study is to screen for the effects of climate change and climate change adaptation in the insurance industry. There is now a consensus that the climate is changing, with potential risk to the global economy and human health and so on. On the other hand, unknown is the extent to which insurance business pattern have already been affected. But the increase in damage due to climate change is likely to raise insurance company losses. In this regard, I conduct especially an effects of the insurance industry on climate change. And than, I analyzed what insurance companies would do to lessen the impact of climate change. As a result, the impact of climate change on the insurance industry is a huge increases in claims due to disasters and diseases arising from climate change. And another thing is growth in climate change-related legislation, regulations and reporting requirements such as financial soundness regulation and climate change risk disclosure. Therefore, the insurance industry needs to build a climate change adaptation strategies include capital raising, liquidity of assets, faithful debt management and so forth.

• 무역상무연구
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• 제67권
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• pp.119-142
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• 2015

Many insurers have traditionally incorporated "fraud clauses" into insurance policies, setting out the consequences of making a fraudulent claim. Even in the absence of an express terms, English courts provide insurers with a remedy for a fraudulent claim. However, the law in this area is complex, convoluted and confused. English Law Commission think that the law in this area needs to be reformed for three reasons; (1) the disjunctive between the common law rule and section 17 generates unnecessary disputes and litigation, (2) increasingly, UK commercial law must be justified to an international insurance society, and (3) the rules on fraudulent claims are functioned as a deterrent if they are clear and well-understood. In order for these purposes, English Law Commission recommends a statutory regime to the effect that, when an insured commits fraud in relation to a claim, the insurer should (1) have no liability to pay the fraudulent claim and be able to recover any sums already paid in respect to the claim, and (2) have the option to treat the contract as having been terminated with from the time of the fraudulent act and, if chosen the option, be entitled to refuse all claims arising after the fraud, but (3) remain liable for legitimate losses before the fraudulent act. LC is not recommending a complete restatement of the law on insurance fraud generally. For example, LC does not seek to define fraud, instead, recommends the introduction of targeted provisions to confirm the remedies available to an insurer who discovers a fraud by a policyholder.

• 한국항해항만학회지
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• 제26권4호
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• pp.399-406
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• 2002

해상선박보험의 역사를 통하여 보면 많은 경우에, 피보험자의 상당주의의무의 결여로 인하여 보험자가 보상을 거부한 경우가 많은 것을 볼 수 있다. 또한 과거 우리나라의 해상사고를 보아도 대부분의 사고가 인적요인에 의해 발생하였음을 알 수 있다. 따라서 본 논문은 이러한 해상손해에 중점을 두고 보험약간과 다른 제반 규칙들을 고찰함으로써 상당주의의무의 필요성에 대해서 강조하며, 나아가 사고사례를 분석하여 상당주의의무의 이행과 그 효과에 대해서 고착하고자 한다.

• 보건행정학회지
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• 제20권4호
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• pp.45-57
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• 2010

Background : If different cost efficiency indexes were informed to the same clinic depending on the inclusion or exclusion of pharmacy cost, it may impair the reliability of provider-profiling system. This study aimed to investigate whether the omission of pharmacy cost affects cost-efficiency rankings in medical clinics. Methods : Data for ambulatory care cost at 23,112 medical clinics were collected from the claims database, which was constructed after review by the Health Insurance Review and Assessment Service (HIRA) of Korea in April 2007. We calculated two types of cost efficiency indexes by inclusion or exclusion of pharmacy cost for a medical clinic. The agreement between the decile rankings of the two indexes was also assessed using the weighted kappa statistic of Landis and Koch. Results : When the cost efficiency index for total cost including pharmacy cost was compared with the index for total cost excluding it, the agreement between the two indexes was only 55%. The agreements between the two indexes were relatively low within specialties which have larger pharmacy volume of total cost and lower correlation between total cost with or without pharmacy cost included than the average level of all the specialties. Conclusion : These results suggest that the omission of pharmacy cost may result in contradictory outcomes that may be confusing to a medical institution and may impair the reliability of provider-profiling systems. It is very important to standardize profiling criteria for the reliability of provider profiling system.

• Journal of Dental Anesthesia and Pain Medicine
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• 제21권5호
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• pp.461-469
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• 2021

Background: The global population is aging rapidly, and accordingly, the number of patients with dementia is increasing every year. Although the need for dental treatment increases for various reasons in patients with dementia, they cannot cooperate during dental treatment. Therefore, behavioral management, including sedation (SED) or general anesthesia (GA), is required for patients with dementia. Thus, this study aimed to investigate the trends and effects of SED or GA in patients with dementia undergoing dental treatment in South Korea based on the Korean National Health Insurance claims data. Methods: This study utilized customized health information data provided by the Health Insurance Review and Assessment Service. Among patients with records of using sedative drugs during dental treatment from January 2007 to September 2019, patients with the International Classification of Diseases-10 code for dementia (F00, F01, F02, F03, and G30) were selected. We then analyzed the full insurance claims data for dental care. Age, sex, sedative use, and dental treatment of patients were analyzed yearly. In addition, the number of cases of GA or SED per year was analyzed, and changes in behavioral management methods with increasing age were investigated. Results: Between January 2007 and September 2019, a total of 4,383 (male, 1,454; female, 2,929) patients with dementia received dental treatment under SED or GA. The total number of SED and GA cases were 1,515 (male, 528 ; female, 987 ) and 3,396 (male, 1,119 ; female, 2,277) cases, respectively. The total number of cases of dental treatment for 4,383 patients with dementia was 153,051 cases, of which 2.22% were under GA and 0.98% were under SED. Midazolam was the most commonly used drug for SED. Conclusion: Although gingivitis and pulpitis were the most common reasons for patients with dementia to visit the dentist, GA or SED for patients with dementia was frequently used in oral and maxillofacial or periodontal surgery.

• Journal of Preventive Medicine and Public Health
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• 제56권3호
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• pp.248-254
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• 2023

Objectives: Measuring the quality of care is paramount to inform policies for healthcare services. Nevertheless, little is known about the quality of primary care and acute care provided in Korea. This study investigated trends in the quality of primary care and acute care. Methods: Case-fatality rates and avoidable hospitalization rates were used as performance indicators to assess the quality of primary care and acute care. Admission data for the period 2008 to 2020 were extracted from the National Health Insurance Claims Database. Case-fatality rates and avoidable hospitalization rates were standardized by age and sex to adjust for patients' characteristics over time, and significant changes in the rates were identified by joinpoint regression. Results: The average annual percent change in age-/sex-standardized case-fatality rates for acute myocardial infarction was -2.3% (95% confidence interval, -4.6 to 0.0). For hemorrhagic and ischemic stroke, the age-/sex-standardized case-fatality rates were 21.8% and 5.9%, respectively in 2020; these rates decreased since 2008 (27.1 and 8.7%, respectively). The average annual percent change in age-/sex-standardized avoidable hospitalization rates ranged from -9.4% to -3.0%, with statistically significant changes between 2008 and 2020. In 2020, the avoidable hospitalization rates decreased considerably compared with the 2019 rate because of the coronavirus disease 2019 pandemic. Conclusions: The avoidable hospitalization rates and case-fatality rates decreased overall during the past decade, but they were relatively high compared with other countries. Strengthening primary care is an essential requirement to improve patient health outcomes in the rapidly aging Korean population.

• 한국중재학회지:중재연구
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• 제15권2호
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• pp.125-162
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• 2005

This paper examined excluded risks of insurer in marine insurance generally, and found out the existing studies on the excluded risks, which were accomplished partially and fragmentarily, to conduct a comparative analysis of marine insurance based on the general flow of claim adjustment. It arranges the existing studies to settle a dispute between the parties -insurer and assurer- and studies the excluded risk based on risk change of the insured by analyzing characteristic and class of security violation, and meaning, form, effect of risk change. it inquires into and analysis cases of the Korean Supreme Court related to the exclusion and illegal act of marine insurance to compare marine theorists' opinion with commercial law.