"Nodules and Calcification are Fine?"... Relying Solely on Insurance Agents' Words Could Lead to 'Violation of Duty to Disclose'

Cases are occurring where, after relying solely on an insurance agent's explanation at the time of enrollment and failing to report past medical history, insurance claims are rejected or contracts are terminated due to a 'violation of the duty to disclose' upon a subsequent cancer diagnosis, necessitating caution.

According to a video from Kim Do-hyeong's Insurance Compensation TV claims adjuster, disputes are arising among policyholders with histories of cystic breast tumors, benign tumors, calcification, or nodules who did not disclose these facts when signing up for insurance. Some agents guide clients by citing Financial Supervisory Service dispute mediation cases or precedents, stating that "nodules or calcification do not have a direct causal relationship with cancer, so there is no need to disclose them," but experts point out that this can be a dangerous interpretation.

"Beware of the error of remembering only favorable precedents"... Comprehensive interpretation is essential

The video warned of the gap between an agent's guidance and actual legal precedents. Claims adjuster Kim Do-hyeong emphasized that "when specific precedents or dispute mediation cases arise, the human brain tends to remember and interpret only the parts favorable to itself," and stressed that Financial Supervisory Service cases should not be interpreted simplistically.

In reality, if nodules or calcification are discovered and medical staff recommend visiting a university hospital, stating that "additional or detailed examinations are required," this may be a condition that goes beyond a simple abnormal finding. This is because the duty to disclose before an insurance contract includes questions related to 'additional or re-examinations' as well as whether a cancer diagnosis was previously received. If a person signs up for insurance without disclosing a recommendation for a detailed examination that remains in their hospital records, it serves as grounds for the insurer to claim a violation of the duty to disclose.

In particular, even if a policyholder has not received a cancer diagnosis in the past, if they signed up for insurance knowing there was some abnormality, the insurer can claim a violation of the duty to disclose if that problem is confirmed as cancer after a certain period of time. Therefore, to resolve issues regarding the violation of the duty to disclose, one must closely observe all medical records, such as how the patient came to visit the hospital, what tests they received in the past, and which hospitals they attended. Kim Do-hyeong explained, "One must predict how far the insurance company will investigate, and from a claims adjuster's perspective, one should prepare for a response in advance by investigating all the hospitals the patient attended, in the same manner that the insurance company conducts its investigation."

A diagnosis certificate alone is insufficient... 'Biopsy and Pathology Reports' are key

Another issue surrounding the payment of cancer diagnosis benefits is the 'appropriateness of the diagnosis.' In the case of breast cancer, even if it is simply labeled as 'breast cancer' on a diagnosis certificate, the payout amount can vary significantly depending on whether it is classified as a general cancer or a minor cancer (carcinoma in situ/CIS) according to the insurance payout standards.

The presenter advised that when claiming insurance benefits, one must check the 'biopsy report' and 'pathology report' in addition to the diagnosis certificate. While a doctor can judge only whether a condition is malignant clinically, insurance companies use these documents as a basis to strictly categorize the type of cancer. In particular, if the diagnosis content is ambiguous, situations may arise where the insurer requests a 'medical consultation' and withholds the insurance payout.

Reinforcing 'Doctor's Opinion' is a practical defense rather than refusing medical consultation

If an insurer requests a medical consultation, refusing it can lead to continued delays in the insurance payout, making it difficult to respond realistically. In response, the video suggested that a way to receive insurance benefits smoothly while avoiding 'medical consultation' is to secure a specific 'doctor's opinion' that can eliminate ambiguous parts in the biopsy report.

It explained that rather than simply submitting a diagnosis certificate, obtaining an additional opinion from a doctor that clarifies the disease falls under general cancer based on the pathology report is a way to simultaneously reduce controversies over the violation of the duty to disclose and disputes over diagnosis classification. Kim Do-hyeong urged, "When claiming insurance benefits alone, one should first examine the violation of the duty to disclose and hospital records, and if the diagnosis is ambiguous, one should obtain an opinion in advance to lower the risk of claim rejection or contract termination."