FSC: Will Reconsider Surgical Coverage Mechanism After Receiving Data from MOHW

(CNA) - The Financial Supervisory Commission (FSC) stated today that insurers have indicated that even with a surgical coverage mechanism in place, it remains unclear whether specific surgeries have largely shifted from inpatient to outpatient procedures. Currently, the industry is more certain about coverage for cataract surgery. To determine if other surgeries are similarly suitable for a general policy, the Ministry of Health and Welfare (MOHW) needs to provide data for clarification, which will form the basis for further discussions with insurers.

For surgeries currently performed on the public, those with high substitutability between inpatient and outpatient settings, and where insurance companies bear a risk-reward relationship, insurers have adopted a flexible approach. This means that even if a patient undergoes an outpatient surgery instead of an inpatient one, they may still receive benefits related to inpatient surgical items, with decisions made on a case-by-case basis.

Tsai Huo-yen, deputy director of the FSC's Insurance Bureau, explained that in response to advancements in medical technology and to protect policyholder rights, the FSC had previously requested the Life Insurance Association of the Republic of China (LIROC) to inform its member companies that for medical surgical items for which premiums are collected, a risk-reward relationship exists, and the condition of high substitutability is met, insurers should, on a case-by-case basis, reach an agreement with policyholders or adopt a lenient interpretation, even if the policyholder does not meet the inpatient criteria.

Tsai further elaborated that due to medical advancements, some surgeries that previously required hospitalization can now be completed with outpatient procedures. The FSC had previously asked the General Insurance Association of the Republic of China and LIROC to conduct an inventory. Insurers reported that even with existing coverage flexibility, it is still unclear in medical practice whether all such procedures have shifted to outpatient care. Therefore, this feedback has been relayed, and the MOHW has been asked to provide data to support whether specific types of surgeries have indeed become predominantly outpatient procedures. With relevant data, discussions on feasible approaches can continue under the principles of fairness, reasonableness, and equitable consideration.

Tsai further explained that this matter relies on scientific methods and data support to focus on whether, besides cataract surgery, there are second or third general surgical items that could be covered flexibly. There is currently no timeline, and discussions will continue.

The LIROC recently stated that although changes in medical practices due to advancements have altered treatment patterns, and insurance companies retain discretion on a case-by-case basis, the premise for flexible coverage remains "the collection of premiums and the existence of a risk-reward relationship." Considering that policy terms vary across different periods and companies, the LIROC issued a letter on March 20th explaining that if an insured person suffers from a disease within the scope of coverage and meets either the "substitutability" or "appropriateness" criteria, insurers may adopt an agreement or lenient interpretation, providing benefits comparable to surgical items of equivalent scope within the policy terms. (Editor: Chang Chun-mao) 1150707

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