• Title/Summary/Keyword: medical risk selection

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Role of the medical claims review (의적클레임검토의 역할 및 기능)

  • Lee, Sin-Hyung
    • The Journal of the Korean life insurance medical association
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    • v.26
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    • pp.31-39
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    • 2007
  • Background and main issue: In the Korean insurance market, an outstanding issue is the decrease of margin of risk ratio. This affects the solvency and profitability of insurance companies. Insurance medicine, which has been developed in Western countries, is so-called medical risk selection or medical underwriting. Medical risk selection is based on clinical follow-up study and mortality analysis methodology. Unfortunately, there have been few clinical follow-up studies, and no intercompany disease analysis system is available in the Korean insurance market. In practice, we use underwriting guidelines, which were developed by some global reinsurance companies. However, these guidelines were developed under clinical follow-up studies performed abroad. So, we cannot rule out underestimation of excess mortality factors such as mortality ratio, excess death rate, and life expectancy. It is necessary to perform medical assessment in claims administration. Comparing the insured's statement by medical records with products' benefit according to this procedure, we can make sound claim decisions and participate in the role of sound underwriting. We can call this scientific procedure as the verification of medical claims review. Another area of medical claims review is medical counsel for claims staff. Result: There is another insurance medicine in addition to medical risk selection. Independent medical assessment by medical records of insured is medical claims review. Medical claims review is composed of verification and counsel.

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A study on the effective administration of medical risk selection system for life insurance (보험진단제도의 효율적 운영에 대한 연구)

  • Ham, Dong-Un;Chun, Jin-Man;Shim, Suk-Kyueng
    • The Journal of the Korean life insurance medical association
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    • v.27 no.2
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    • pp.85-95
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    • 2008
  • When an insurance company receives an application for life or health insurance, the company must evaluate the degree of risk the individual for insurance coverage presents before the company agrees to issue the policy. A medical factor is a physical or psychological characteristic that may increases a hazard. A financial factor is financial information that is taken into account by underwriter to determine if a person is applying for more than he/she reasonably needs or can afford. A personal factor is a lifestyle choice. There are several medical risk selection systems in Korean life insurance market. They are attending physician's statement, direct examination by insurance doctors, and paramedic examination. However there is some dissatisfaction of current system. It is possible that cooperation of part-time insurance doctors system may be one of useful system of medical risk selection. Improvement of medical risk selection system will be an important matter of profitability of insurance company and it will contribute to sound life insurance system.

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Establish Selection Process of Performance Management Medical Devices and Test items Based on Risk Management (위험관리기반의 성능관리 의료기기 선정 절차 수립 및 시험 항목 도출)

  • Park, Ho Joon;Jang, Joong Soon
    • Journal of Biomedical Engineering Research
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    • v.40 no.1
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    • pp.20-31
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    • 2019
  • Medical device performance management is an activity that allows a device to be safely used and maintained even after it is put on the market. The purpose of this study is to provide procedures and criteria for selection of medical device items that should manage the safety and performance among medical devices in hospital. Investigate the performance management status of medical devices in hospitals and identify the performance management status by domestic and advanced regulatory agencies. Provides selection procedures and test methods for medical devices subject to performance management in hospitals based on medical device risk management and reliability. In addition, a case study on drug infusion pumps was conducted.

Claims Insurance Medicine (클레임보험의학)

  • Lee, Sin-Hyung
    • The Journal of the Korean life insurance medical association
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    • v.30 no.2
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    • pp.8-11
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    • 2011
  • Insurance medicine has been known to medical risk selection. The role of insurance medicine is sound maintenance of insurance system. So it's function is medical underwriting of life risks. However, emerging market has insufficient medical epidemiological research that is necessary for estimation of extra-risk and such market is usually lack of full understanding of life insurance among insurance customers. This problem makes difficult of performing the medical underwriting, as an original insurance medicine. Medical contributions at the stage of claims adjudication comparing the coverage provided in the product, with the information provided in the claims, based on medical records and the agreement between them. This is called medical verification. The insurance doctors can also use their medical knowledge to help the claims staff with informing claimants about the medical basis of claims decisions.

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Insurance risk analysis of drug-resistant tuberculosis (내성결핵의 보험의학적 위험분석)

  • Lee, Sin-Hyung
    • The Journal of the Korean life insurance medical association
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    • v.28 no.1_2
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    • pp.15-18
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    • 2009
  • Background: Recent emergence of drug-resistant tuberculosis such as multidrug-resistant tuberculosis(MDR-TB) or extensively drug-resistant tuberculosis(XDR-TB) has become important health care problems. It has also became grave issues for insurance industries in determining medical risks. We have therefore strived to analyze the comparative mortality rates for drug-resistant tuberculosis through utilization of results from previous articles. Methods: Comparative mortality was calculated from source articles using mortality analysis methods. Results: Mortality ratio of MDR-TB was estimate to 1200%, and excess death rate was 110 per 1,000. Comparative mortality between MDR-TB and XDR-TB by Korean $study^{(1)}$ were 1750, 382, 405, 443, 1025, and 357%, for each 10 months study intervals, respectively. Total mortality ratio was 594% and total excess death rate was 60 per 1,000person. It was determined that the risk of XDR-TB was much greater than MDR-TB. Discussion; Pending the development of a novel anti-tuberculosis drug, it would be prudent to steer clear insuring XDR-TB during underwriting phase due to high medical cost that it creates.

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Outcomes of Gastrectomy for Gastric Cancer in Patients Aged >80 Years: A Systematic Literature Review and Meta-Analysis

  • Zelalem Chimdesa Merga ;Ji Sung Lee ;Chung-Sik Gong
    • Journal of Gastric Cancer
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    • v.23 no.3
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    • pp.428-450
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    • 2023
  • This meta-analysis examined the surgical management of older patients (>80 years) with gastric cancer, who were often excluded from randomized controlled trials. We analyzed 23 retrospective cohort studies involving 18,372 patients and found that older patients had a higher in-hospital mortality rate (relative risk [RR], 3.23; 95% confidence interval [CI], 1.46-7.17; P<0.01) and more post-operative complications (RR, 1.36; 95% CI, 1.19-1.56; P<0.01) than did younger patients. However, the surgical complications were similar between the two groups. Older patients were more likely to undergo less extensive lymph node dissection and longer hospital stays. Although older patients had statistically significant post-operative medical complications, they were not deprived of surgery for gastric cancer. The comorbidities and potential risks of post-operative complications should be carefully evaluated in older patients, highlighting the importance of careful patient selection. Overall, this meta-analysis provides recommendations for the surgical management of older patients with gastric cancer. Careful patient selection and evaluation of comorbidities should be performed to minimize the risk of post-operative complications in older patients, while recognizing that they should not be deprived of surgery for gastric cancer.

The Assessment of Risk of Bias on Clinical Studies of Herbal Treatment for Acne (여드름의 한약 치료 임상연구에 대한 비뚤림 위험 평가)

  • Park, Hye-ryun;Roh, Seok-sun
    • Journal of Haehwa Medicine
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    • v.24 no.1
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    • pp.15-24
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    • 2015
  • Objectives : This study was carried out to assess the risk of bias of clinical trials on acne treatment with herbal medicine that have been published in Korea. Methods : 7 electronic databases in Korea were searched for clinical trials on acne treatment. Two independent reviewers selected clinical trials on herbal medicine treatment for acne. Selected studies are categorized according to DAMI(Study Design Algorithm for Medical literature of Intervention). RCTs are assessed according to Cochrane RoB(Risk of Bias), non-randomized studies(Before-after studies) are assessed according to RoBANS(Risk of Bias Assessment tool for Non-randomized Study). Results : After selection process, 25 articles are left. Among 25 articles, 3 RCTs and 4 before-after studies are finally included. In RCTs, the proportion of 'unclear' is high in criteria of 'random sequence generation', 'allocation concealment', and 'blinding'. In before-after studies, 'high' is high in criteria of 'blinding for outcome assessment' and 'incomplete outcome data'. Conclusions : Considering the above results of the assessment, it is necessary to conduct more well designed clinical trials on acne treatment with herbal medicine.

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