“Brief stays in the hospital, regular nights at the bar” ... A hospital-hopping patient hospitalized for more than 200 days [Filing False Claims]

[Financial News] Soon after being discharged from one hospital, A was admitted to another. The diagnosis was the same. Admissions and discharges kept recurring, but A spent little time in the hospital room.At night, A would slip out of the hospital to drink and leave the prescribed medication at home, where it lay unusedEven so, A filed claims with the insurer as if A had received inpatient care as usual.
A was unlike ordinary patients. After receiving treatment at one hospital, A was discharged and admitted to another with the same diagnosis just days later. At one hospital, too, A cited the same illness as the reason forrepeated admissions and dischargesas well.
The problem was that many cases were identified in which hospitalization itself was unnecessary or continued beyond the period required for treatment. Even the medical staff’songoing observation or special treatment was not particularly necessary, yet A remained in the hospital room.
An analysis of A’s medical records by the Health Insurance Review & Assessment Service (HIRA) found that the number of days A spent hospitalized beyond the appropriatehospitalization period was close to 200 days. In most of the offenses, the appropriate hospitalization period was exceeded by at least one week. In this way,the insurance benefits A fraudulently obtained amounted to about 15 million won.
A tip-off from A’s former romantic partner, B, played a decisive role in exposing A’s insurance fraud. B alerted an insurance company to suspicions that A had committed insurance fraud. During a subsequent police investigation, B said that A had once bragged about obtaining insurance payouts.
There was also testimony about A’s conduct during hospitalization. According to B, A did not take the medication prescribed at the hospital, but brought it home and threw it away. Even while receiving inpatient treatment, A slipped out of the hospital every night to drink. The medical records, too, were replete with entries noting that A had gone out without authorization during the hospitalization and had not been in the hospital room.
A’s prior history of insurance fraud also worked against A at trial. A had previously been hospitalized more than 50 times over about six years. In total, the hospital stays amounted to nearly 1,300 days. Around 40% of them were deemed unnecessary or longer than the appropriate period.
This time as well, A was indicted for violating the Special Act on Prevention of Insurance Fraud and, at the first trial, was sentenced tothree months in prison, suspended for two years, for some offenses, and six months in prison, suspended for two years, for the remaining offensesrespectively.
A appealed, arguing that the sentence was too harsh, but the panel dismissed the appeal and upheld the lower court’s ruling. The central issue at trial was whether insurance fraud could be established even if a person had actually been admitted to a hospital. A argued that the admission had been based on the medical institution’s judgment and that A had received actual treatment, so the insurer had not been deceived.
The court, however, found that whether someone was hospitalized could not be determined solely by how much time they spent in a hospital room.The patient’s symptoms and diagnosis, the nature and circumstances of the treatment, and the patient’s conduct during hospitalization must all be considered togetherthe court said, citing Supreme Court of Korea precedent.
The court also made clear that fraud is established if someone extends a hospital stay with the intent to obtain more in insurance benefits than they could actually receive, even if there is some basis for receiving benefits. The appellate panel stated, “The sentence imposed by the lower court is appropriate and cannot be deemed unfairly harsh to the point of exceeding the reasonable bounds of its sentencing discretion.”

[email protected] Kim Tae-il Reporter