보험의학회지 (The Journal of the Korean life insurance medical association)
- 제26권
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- Pages.41-53
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- 2007
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- 1976-264X(pISSN)
의적클레임검토 유형론
Typology of the medical claims review
- 이신형 (SIS 특종상해손해사정(주) 파라메딕)
- Lee, Sin-Hyung (SIS casuality insurance claim adjustment Co. Ltd)
- 발행 : 2007.07.20
초록
In the course of insurance claim administration, medical experts' opinions are called medical claim reviews. They are classified into two main categories: medical verification and counsel for claim staff. Medical verification compare between product coverage and the insured's physical condition. Medical counsel for claim staff is advice for claim staff when they have a question about medical knowledge to make a claim decision. A common example of medical verification is insurance coding of pituitary apoplexy. Some clinicians have insisted that the ICD coding of pituitary apoplexy is l63 of cerebral infarction, but the exclusion criteria of I code show that neoplasm is coded as C00 to D48. Thus, pituitary apoplexy must be coded as D33. An example of medical counsel for claim staff is interpretation of some medical conditions. It is divided into UCR(usual, customary, and reasonable) assessment, assessment of causality, and so on. Disability evaluation is another subject of medical counsel for claim staff. The final claim decision must be made by claim staff because only the claim staff have the authority of claim decision. Medical claims review is only an expert's opinion.