Same-Day Surgery to Be Treated as Inpatient for Insurance Claims? Life Insurers: Unlikely to Relax Criteria

(Central News Agency, reporter Su Siyun, Taipei, June 6) Regarding the issue raised by legislators on whether "same-day surgery" should be treated as inpatient for insurance claims, the Life Insurance Association is expected to hold discussions on the 10th. Life insurers point out that the key to claims lies in whether hospitalization procedures were completed. For "same-day surgery," if hospitalization procedures were completed, claiming inpatient benefits is not a major problem. However, it is unlikely that procedures which are essentially outpatient surgeries will be further relaxed and treated as inpatient surgeries for benefit payments.

The amendment to the Medical Care Act passed its third reading on May 8, officially codifying the three-shift nurse-to-patient ratio into law, with phased implementation planned. National Taiwan University Hospital previously proposed gradually converting surgeries that originally required 2.5 days of hospitalization into "same-day surgeries" to reduce the burden on night-shift nursing staff. However, many people's existing insurance policies are based on hospitalization for claims. As medical centers promote same-day surgeries allowing discharge on the same day, legislators are concerned about whether this will affect claims for inpatient items in insurance policies.

The Financial Supervisory Commission (FSC) stated it will take inventory of related insurance products on the market, with deliberations expected within one month. Subsequently, it will ask the property and casualty insurance association and the life insurance association to hold meetings to discuss countermeasures.

According to sources, the Life Insurance Association is collecting opinions from the industry and plans to hold a meeting on June 10 to discuss whether, under the trend of same-day surgery, procedures that are essentially outpatient surgeries can be further relaxed and treated as inpatient surgeries for claims.

Currently, different hospitals handle this differently. Some hospitals have what is called "same-day inpatient surgery," where patients complete admission procedures on the day of surgery and can be discharged the same day. Other hospitals do not have this distinction and only classify surgeries as overnight inpatient surgery or outpatient surgery.

A senior life insurance executive pointed out that "same-day surgery" is not a new issue. In recent years, with advances in medical technology, surgeries that previously required several days of hospitalization have become "same-day surgeries" due to the adoption of minimally invasive techniques.

However, life insurers noted that current hospital practices for "same-day surgery" may vary. If a patient undergoes "same-day surgery" after completing admission procedures, they can claim inpatient surgery benefits. If admission procedures are not completed, they would claim outpatient surgery benefits. Therefore, the overall determination must be based on the policy terms. The key is whether hospitalization procedures were completed. If so, inpatient-related items will still be covered.

An industry insider gave an example: for a surgery that previously required a 3-day hospital stay but is now a same-day surgery, if admission procedures were completed (i.e., admitted and discharged on the same day), the policy would still cover inpatient items, but the benefit would be reduced from 3 days to 1 day. However, if no admission procedures were completed, it would be considered an outpatient surgery, and coverage would depend on whether the policy includes outpatient surgery benefits.

Regarding the possibility of further relaxing current outpatient surgeries to be treated as inpatient surgeries for insurance claims, life insurers generally believe it is impossible.

Insurers emphasized that for surgeries that are highly substitutable between inpatient and outpatient settings, and where the insurance company indeed bears a risk consideration, the company can handle cases on an individual basis through negotiation or flexible interpretation with the policyholder. This is already considered a form of relaxation. However, to further expand this to a broader, blanket comparison for claims, the accounting would be very difficult to calculate. (Editor: Lin Shuyuan) 1150606