Claimed Prostate Cancer Diagnosis Benefit... But Insurance Payment Denied Due to 'Recommendation for Re-examination' Records

Caution is required as cases are occurring where an insurance contract is terminated and the payment of insurance benefits is denied due to the phrase 'recommendation for re-examination' left in past medical records, even after a person is diagnosed with prostate cancer and claims insurance benefits.

According to a video from Kim Do-hyeong's Insurance Claims TV, in a recent case of a man diagnosed with early-stage prostate cancer, the insurance company notified him of contract termination and non-payment of benefits based on a violation of the duty of disclosure. The core of this case is not simply the fact that the PSA (Prostate-Specific Antigen) level was high, but the medical records left by a doctor during a past visit to a urology department.

The 'Recommendation for Re-examination' Record More Terrifying Than PSA Levels

While many policyholders believe that a high PSA level is directly linked to cancer, the video explains that an increase in PSA levels can also be caused by prostatitis or benign prostatic hyperplasia. It is common for a doctor, after confirming an increase in PSA levels, to advise, "Come back in 6 months" or "Undergo a detailed examination."

The problem lies in the insurance company's judgment criteria. Insurance companies check not only whether a patient was diagnosed with cancer but also whether the patient was previously recommended for 'additional tests, re-examinations, or detailed examinations' at a hospital. A patient may think they simply visited for a regular check-up, but if phrases such as 'detailed examination scheduled' or 'recommendation for re-examination' remain in the medical records, the insurance company can use this as grounds for violating the duty of disclosure to terminate the contract. In other words, the past medical records from primary or secondary hospitals become a decisive variable in applying the violation of the duty of disclosure rather than the final diagnosis records from university hospitals.

The Uncertainty of the 'Biopsy Result Sheet' More Important Than the Diagnosis Certificate

What determines whether the cancer diagnosis benefit is paid is not the diagnosis certificate issued by the doctor, but the 'biopsy result sheet.' The video pointed out that in the case of prostate cancer, there is a large difference in the reliability of the diagnosis before and after surgery. Because a pre-surgical biopsy collects only very small areas to observe under a microscope, ambiguous expressions such as 'suspicious' or 'rule out' are often written on the result sheet.

Insurance companies use the uncertainty of these result sheets as grounds to request medical consultation, thereby delaying or denying the payment of insurance benefits. If the result of the medical consultation comes out as "cannot confirm if it is a malignant tumor" or "re-evaluation is required after surgery," insurance companies show a typical pattern of denying the insurance payment using this as an excuse. If one carelessly agrees to the medical consultation proposed by the insurance company at this time, there is a high risk of ultimately not receiving the insurance benefits.

Disputes Between General Cancer and Small-sum Cancer, Checking Terms and Conditions is Essential

Disputes over prostate cancer insurance benefits also occur in the cancer classification system. Depending on the insurance terms and conditions, prostate cancer may be classified as 'general cancer,' but it may also be classified as 'small-sum cancer (carcinoma in situ, intraepithelial carcinoma, etc.)' or excluded as a separate item altogether. If a policyholder did not receive sufficient explanation regarding these classification criteria at the time of enrollment, it leads to consumer complaints as they receive a much smaller amount than the expected diagnosis benefit.

Ultimately, to avoid prostate cancer insurance disputes, one should not stop at simply submitting a diagnosis certificate, but must check what phrases are left in their own past medical records and closely examine the expressions on the biopsy result sheet. In particular, since the medical consultation requested by the insurance company can be the basis for denial of payment, a cautious approach is required.