benefits system & preventive measures against insurance fraud workers’ compensation insurance...

Benefits system & Benefits system & Preventive Preventive

Measures against Measures against Insurance FraudInsurance Fraud

Workers’ Compensation Insurance Workers’ Compensation Insurance in Koreain Korea

By JOOYUNG By JOOYUNG KIMKIM

E-mail : [email protected] : [email protected]

2

ContentsContents

Type of Benefits and Criteria2

3

4 Discussion Topic

Outline of Benefits1

Insurance Fraud and Its Preventive Effort

3

11 Outline of Benefits

> Description of benefits according to the stage of physical condition

Accident happens Claimant diesTreatment ends Treatment resumes Treatment ends

2 years

Temporary disability benefits

Medical benefits


Injury-disease compensation

annuities

Lump-sum payment of Benefits (in case of migrant workers departing from Korea)

Medical benefits


Permanent disability benefits

Nursing benefits

Vocational rehabilitation benefits

Permanent disability benefits

Nursing benefits

Vocational rehabilitation benefits

Sport therapy

6 months

Medical treatment of aftermath

Medical treatment of aftermath

Funeral expenses Survivors benefitThy do not belong to benefits and could be available in accordance with COMWEL financial status

4

Temporary Disability BenefitsMedical Benefits

Permanent DisabilityBenefits

Injury-Disease Compensation Annuity

Survivors Benefits

Funeral Expenses

Types of Types of BenefitsBenefits

Nursing Benefits

22 Types of Benefits and Criteria

Vocational Rehabilitation Benefits

WCI Management & Operation

(COMWEL)

Beneficiaries (injured workers,

survivors/dependents)

Policy Holders(insured employers)

Payment of contributions

Exemption from liability for accident compensation of Labor

Standards Act

Claim for benefits

Stability in livelihood

Payment of benefits

Labor

COMWEL

COMWEL

6

The Number of Compensation & Trend of Benefits Amount

The Amount of Benefits

The Number of Compensation

The Number of Beneficiary

3,242,276

3,421,8853,463,141

1,843 12,671

97,141

296,995

1,133,577

1,556,0421,451,066 1,456,266

2,020,335

2,481,814

2,859,914

3,025,7713,163,769 2,326

2,418

2,514

105 98 114 143 162 180 189 197 206 211 240 252

86164

336

635

826957

781

983

1,506

1,732

2,008 2,2212,261

2,329

0

300,000

600,000

900,000

1,200,000

1,500,000

1,800,000

2,100,000

2,400,000

2,700,000

3,000,000

3,300,000

3,600,000

3,900,000

7̀0 7̀3 7̀6 7̀9 8̀2 8̀5 8̀8 9̀1 9̀5 9̀6 9̀7 9̀8 9̀9 0̀0 0̀1 0̀2 0̀3 0̀4 0̀5 0̀6 0̀7 0̀8 0̀9

amount (million won)

- 300

0

300

600

900

1,200

1,500

1,800

2,100

2,400

2,700

number of compensation(1,000)

number of beneficiary(1,000 person)

Statistical Review 1

7

Number of Beneficiary in 2009

Beneficiary

195,486122,656

74,584

16,727780

2,2304,025

6,532

Medical care benefit

Temporary disability benefit

Permanent disability benefit

Surviving benefit

Injury- disease compensationbenefit

Funeral expenses

Nursing benefit

Rehabilitation benefit


8

Amount of Benefits in 2009

Benefi ts

21,963

39,366

1,977189,956

332,550

1,291,084

786,075

800,171

Medical care benefit

Temporary disabilitybenefitPermanent disabilitybenefitSurvivors benefit

Injury-diseasecompensation benefitFuneral expenses

Nursing benefit

Rehabilitation benefit

unit : million won


9

Number of Beneficiary by Industry in 2009

Benefi ciary

13,275

1,727

75,025

13,384

58,954 89,476

437

Finance, Insurance

Minery

Manufacture

Electric, gas, water

Construction

Transportation, Storage,Telecommunication

The others


10

Amount of Benefits by Industry in 2009

Benefi ts

323,329

23,667

645,534

177,811

1,082,601

1,200,629

9,570

Finance, insurance

Minery

Manufacture

Electric, gas, water

Construction

Transportation, storage,telecommunication

The others

unit : million won


11




Survivors Benefits

Funeral Expenses


Nursing Benefits



How much How much WhenWhen How much When How much When

Medical care

benefit

Medical care

benefit

Occurrence of work-related injury or disease requiring medical treatment for 4 days or more

Occurrence of work-related injury or disease requiring medical treatment for 4 days or more

Benefit in kind in principleMedical expenses in special case

Benefit in kind in principleMedical expenses in special case

Medical BenefitsMedical Benefits

13

> The scope of Medical Benefits

1. Medical examination and test2. Provision of medicines or medical supplies, artificial limbs, and other prosthetic devices3. Treatment, operation and other treatments4. Rehabilitation treatment5. Hospitalization6. Nursing and patient caring7. Transfers8. Other matters prescribed by the Ordinance of the Ministry of Employment and Labor.

Medical BenefitsMedical Benefits

Application Form for Medical Care Benefits

16




Survivors Benefits

Funeral Expenses


Nursing Benefits




Off work for 4 days or more due to the medical treatment of work-related injury or disease

Off work for 4 days or more due to the medical treatment of work-related injury or disease

• 70% of the average wage• 70% of the average wageTempo-rary

disability benefit

Tempo-rary

disability benefit

Temporary Disability Temporary Disability BenefitsBenefits

Application Form for Temporary Disability Benefits

19

Temporary Disability Temporary Disability BenefitsBenefits

The Types of BenefitsThe Types of Benefits

90% of (DAW x working time

/ 8)- actual income per

time)

PLUS

(DAW x 70%) xoff time/8

Low-income workers

70% of DAWor

Minimum wage

Minimum wageor

90% of DAWor

80% of MSAC

Partially employed workers during medical care

#DAW=Daily Average Wage#MSAC=Minimum Standard Amount of Compensation (In case of 2009, it is 46,933 won per day ($39)# In case of 2009, minimum wage is 32,000 won per day ($2.6)

The Aged Workers

Getting paid 4% decreased TDB per year from

the age of 61 to 65

(-4% -> -20%)

During Additional Medical Care

20




Survivors Benefits

Funeral Expenses


Nursing Benefits




Occurrence of work-related physical or mental disability after recovery

Occurrence of work-related physical or mental disability after recovery

- Grade 1~3 ： pension only （ 257~329 days’ worth of the average wage ）

- Grade 4~7 : pension or lump-sum (pension ： 138~224 days) (lump-sum ： 616~1,012 days)

- Grade 8~14 ： lump-sum only （ 55~495 days)

- Grade 1~3 ： pension only （ 257~329 days’ worth of the average wage ）

- Grade 4~7 : pension or lump-sum (pension ： 138~224 days) (lump-sum ： 616~1,012 days)

- Grade 8~14 ： lump-sum only （ 55~495 days)

Perm-anent

Disabilitybenefit

Perm-anent

Disabilitybenefit

Permanent DisabilityPermanent Disability Benefits Benefits

Disability Grade Pension Lump-sum

1 329 day’s worth 1,474 day’s worth




5 193 day’s worth 869 day’s worth



8 　 495 day’s worth







Table of Permanent Disability Benefit

23


ReasonsReasons of benefits payment,Timing for claims and benefits amounts

(1) Benefits amounts

The amount of Permanent Disability Benefits are

various, depending on the Disability Grade.

Ex) the benefits amount of Disability Grade 14 is equivalent to 55 day's worth of average wage.

if the average daily wage = 10$, disability grade = 14

then, the benefits amount = 550$(55 x 10$)

Permanent Disability BenefitsPermanent Disability Benefits

24



The formula of the Permanent Disability Benefits in Lump Sum payment

The amount of lump sum =

The average (daily) wage at that time of claiming the P.D.B. ×

The number of the compensation day's worth of average wage in lump sum.


25



The formula of the Permanent Disability Benefits in Pension payment

The amount of pension =

The average wage at recovery × The number of the compensation day's worth of average wage in pension.

Ex) the benefits amount of Disability Grade 1 is equivalent to 329 day's worth of average wage. if the average daily wage = 10$, disability grade = 1 then, the amount of the monthly pension = 274$(329 x 10$ ÷ 12)


26

Special clauses regarding benefits payment

�

Permanent Disability Permanent Disability BenefitsBenefits

11 A death of a beneficiary

22 Emigration to other country

33 A foreigner beneficiary return to home country

(2) (2) LumpLump sum payment of the differential sum payment of the differential


27


� 11. Advance paymentAdvance payment A beneficiary of Permanent Disability Benefits in pension mayapply for an advance payment equivalent to 1/2 of the pension for the first 1~4 years.

※ A beneficiary with disability of Grades 1~3 may claim advance payment for the first 1~4 years ; and a beneficiary with disability of Grades 4~7, for the first 1~2 years.

※ This advance payment is given to the beneficiary with interest rate(2%) deducted.



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� Example : claim for 2 years advance payment, grade 1, average wage 10$

- half amount in lump-sum in advance payment :

-> average wage(10$) * 329 days’ worth * 2 year * 1 / 2 = 3,290 $

-> 3,290 $ * 99.8% (deduct 2%) = 3,224 $

- half amount in pension : average wage(10$) * 329 days’ worth * 1 / 2 = 1,645 $

-> 1,645 $ / 12 month = 137 $ per month for 2 years

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� 33) Disability Benefits Due to Additional Medical Care Disability Benefits Due to Additional Medical Care

� � In case the beneficiary of permanent disability pension enters into additional medical care, the pension payment used to be suspended.

However, from 1 July 2008 even in case a person entitled to a disability compensation annuity receives medical care, the payment of the annuity shall not be suspended.

If after a person is cured by additional medical care, his/her state of disability has improved or worsened compared with before, the disability benefits shall be paid according to the disability grade corresponding to the improved or worsened state of disability.



30

Permanent Disability BenefitsPermanent Disability BenefitsThe kinds of valuation

basis on disability

11 McBride Valuation basis on Disability

22 14 Grade Scheme

--> It is used for valuation of invalidity in the field of --> It is used for valuation of invalidity in the field of compensation for damage such as automobile compensation for damage such as automobile insurance, civil lawsuit for physical damage in Korea. insurance, civil lawsuit for physical damage in Korea. The percentage and period of labor capability loss are The percentage and period of labor capability loss are mainly considered in this invalidity valuation.mainly considered in this invalidity valuation.

--> --> It is used for valuation of disability in WCI in Korea. It is used for valuation of disability in WCI in Korea. In principle, each grade of disability is considered as In principle, each grade of disability is considered as permanent invalidity. But there is an exception in some permanent invalidity. But there is an exception in some cases, which needs redetermination even after decision cases, which needs redetermination even after decision on disability grade was made.on disability grade was made.


31


Just Once within one year after two years have passed since the day when the decision to pay

disability compensation

annuities was made

Subject to redetermination

Disability compensation

annuities corresponding to the

changed disability grade shall be paid beginning from the

next month of medical exam

Persons entitled to disability

compensation annuities

Period for redetermination



annuities was made

Method of payment

Redetermination of Disability Grades

Category of disability for redetermination

# Neuro-psychotic disorder

#Spinal nerve root disorder

#Motor functions of body joints

#Pneumoconiosis


32

Adjustment of disability grades

� (1) Definition(1) Definition An employee may get hurt in two different part, such as arm and leg, and, even after medical care treatment, there will be possibility to remain disabled in two part.

If an employee has more than one kind of disabilities that are listed in the Permanent Disability Benefits schedule, the Adjustment of Disability Grade might be considered.



33

Adjustment of disability grades

� (2) The purpose of adjustment (2) The purpose of adjustment

If an employee is respectively provided with each disability benefits, according to all of the disabled part in body, the total amount of the Permanent Disability Benefits will be over the amount of Grade 1.

so, that's why adjustment of disability grades has been needed.



34

※ Application to similar permanent disability grade

� In the WCI, Disability Grade Schedule is including 14 Grades and about 140 cases of disability.


But it's so difficult to include all various kinds of disability cases within the WCI Disability Grade Scheduleand, what is described in the WCI Disability Grade Schedule is only the typical cases of all various disability in the world. So, it would happen that one's disability does not always fit exactly in the WCI Disability Grade Schedule.

Even in this case, One will get the most similar grade to one's own.


35

※ In case of disability gotten worse (in other word, summation)

� Those with disability previously may have another disability added on a previous one. This is called "summation"


What is important is that the reason of getting worse should be attributable to "newly work-related accident".

A disability degree may be worse by getting age as time has passed, or by reoccurrence of disease, but, this is not called "summation". Summation is not because of age or reoccurred disease, but because of newly work-related accident.

The purpose of it is to compensate only what did get newly worse, compared with a previous disability.


36

Claims & payment process


The employee submits a written application for disability benefits.

COMWEL notifies the employee of disability review and asks him to turn up for the review

(with an X-ray film, electromyogram test results, etc.)

The disability review is made (by the advisory doctor)

and the disability grade is determined.

The compensation (disability benefits) is paid

to the employee if the COMWEL advisory doctor’s opinion

responds to the opinion of patient’s doctor-in-charge

31

33

2

4


37

Claims & payment process


If there is difference of medical opinion on disability degree between patient’s doctor-in-charge and COMWEL advisory doctor,

COMWEL can ask the opinion of panel of COMWEL advisorydoctors and make the final decision based on the opinion.

Or COMWEL may demand medical examination which Is conducted

by WCI-related medical institution above the level of general hospital.

The compensation (disability benefits) is paid to the employee

after making the final decision based on opinions of doctor-in-

charge, COMWEL advisory doctor, demanded medical examination.

35

35-2

5-1

5-3


Application Form for Permanent Disability Benefits

40




Survivors Benefits

Funeral Expenses


Nursing Benefits



41

Nursing BenefitsNursing Benefits


Nursing Benefits are awarded to an employee whose work-related injury or sickness, even though he has recovered from the injury or sickness, medically requires a constant or occasional nursing.

DefinitionDefinition

This benefit is paid only when such employee actually receives nursing services.

42



Coverage & sub-typesCoverage & sub-types

① Those with disability of Grade 1 with regard to functions of the nervous system, mental sanity or the thoracic or abdominal organs.

② Those with disability of Grade 1 with regard to both eyes, both arms or both legs, along with disability of Grade 7 or higher in other body areas.

① Those with disability of Grade 1 with regard to functions of the nervous system, mental sanity or the thoracic or abdominal organs.

② Those with disability of Grade 1 with regard to both eyes, both arms or both legs, along with disability of Grade 7 or higher in other body areas.

Constant Nursing Benefits are awarded to

43



Coverage & sub-typesCoverage & sub-types

① Those with disability of Grade 2 with regard to functions of the nervous system, mental sanity or the thoracic or abdominal organs

② Those with disability of Grade 1 who are not entitled to the Constant Nursing Benefits (It will also include those whose disability grade is adjusted to Grade 1)

③ Those with disability of Grade 2 with regard to both eyes, both arms or both legs, along with disability of Grade 7 or higher in other body areas.

④ Those who have lost both thumbs and all fingers, thus cannot eat without other's help

⑤ Those whose work-related sickness has rendered them so invalid that they cannot make any move without other's help.

① Those with disability of Grade 2 with regard to functions of the nervous system, mental sanity or the thoracic or abdominal organs

② Those with disability of Grade 1 who are not entitled to the Constant Nursing Benefits (It will also include those whose disability grade is adjusted to Grade 1)

③ Those with disability of Grade 2 with regard to both eyes, both arms or both legs, along with disability of Grade 7 or higher in other body areas.

④ Those who have lost both thumbs and all fingers, thus cannot eat without other's help

⑤ Those whose work-related sickness has rendered them so invalid that they cannot make any move without other's help.

Occasional Nursing Benefits are awarded to

44



Demand and methods of benefitsDemand and methods of benefits

• After receiving the disability benefits, by submitting a Nursing Benefits application form that specifies disabled body parts and everyday life difficulties caused by his disability.

• Those in need of constant nursing shall be awarded the full amount set by the Labor Minister for Nursing Benefits, while those in need of occasional nursing shall be awarded 2/3 of the amount of Constant Nursing Benefits.

• The Nursing Benefits payment shall be made on a monthly basis for the days when nursing services are actually given.

• The number of nurses compensable under the EII is limited to one per employee in need of nursing.

45



※ the principle of nursing benefits payment ※ the principle of nursing benefits payment

11 this benefits is given to those whose disability grade 1, 2, or relevant to it.

22 the actual nursing should have been given to the beneficiary.

33the number of person who has taken care of the beneficiary is limited to only one per beneficiary.

44 this benefits is paid once in a month.

46




Survivors Benefits

Funeral Expenses


Nursing Benefits




Employee’s death or presumed dead due to work-related reasons


- Pension : mandatory (52 ～ 67 ％ of the average wage)- Lump-sum : no eligible for pension (1,300days of the average wage)- 50%lump-sum, 50% pension : choice

- Pension : mandatory (52 ～ 67 ％ of the average wage)- Lump-sum : no eligible for pension (1,300days of the average wage)- 50%lump-sum, 50% pension : choice

Survivors benefits

Survivors benefits

Requiring more medical care after 2 years’ medical treatment and constituting invalidity grade 1~3

Requiring more medical care after 2 years’ medical treatment and constituting invalidity grade 1~3

- Pension(257~329 days of the average wage)

- 93% of the pension for those aged 65 or older

- Pension(257~329 days of the average wage)

- 93% of the pension for those aged 65 or older

Severe disease compensation

pension

Severe disease compensation

pension



- 120days of the average wage- Maximum, minimum : announced

- 120days of the average wage- Maximum, minimum : announced

Funeral expenses

Funeral expenses



• Pension : mandatory (52~67 ％ of the average wage)

• 50% lump-sum, 50% pension (choice)

• Lump-sum : no eligible (1,300 days of the average wage)

• Pension : mandatory (52~67 ％ of the average wage)

• 50% lump-sum, 50% pension (choice)

• Lump-sum : no eligible (1,300 days of the average wage)

Survivors benefit

Survivors benefit

Survivors BenefitsSurvivors Benefits

48



• The amount of the Survivors Benefits may increase by the number of survival family.

• if the number of survival family is just 1, the amount of survivors benefits are equivalent to 52% of average wage.

Methods of benefits paymentMethods of benefits payment

(1) In principle, The Survivors Benefits shall be paid in pension

• if the number is 2, the amount of survivors benefits are equivalent to 57% of average wage.

• if the number is 3, the amount of survivors benefits are equivalent to 62%

• if the number is 4 or more, the amount of survivors benefits are 67%

49



(example)

In case, average (daily) wage is 60$, survival family is wife, one son under 18, the amount of the survivors benefits are like this : 60$ × 0.57 × 365 = 12,483$ (annually)


(1) In principle, The Survivors Benefits shall be paid in pension

* 365 : As this survivors benefits are annuity, the number of days in a year is needed.

* 0.57 : the number of survival family is 2, and the amount of survivors benefits are equivalent to 57% of average wage.

* the amount of survivors benefits paid every month would be around 1,040$

; 12,483$÷ 12(the number of month in a year)

50



• Upon request of the pension beneficiary, 50% of the survivors benefits may be awarded in a lump sum and the remaining 50% may be paid in pension

The amount of the survivors benefits is relevant to 1,300 day's worth of average wage.


(2) 50% in lump sum payment

1,300 day's worth of average wage means like this ;

1,300 × average (daily) wage

51



(example)

In case, average (daily) wage is 60$, survival family is wife, one son under 18, wife requested the COMWEL pay 50% in lump sum, the amount of the 50% of survivors benefits in lump sum : 60$ × 1,300 × 50% = 10,950$


(2) 50% in lump sum payment

the total amount of the survivors benefits pension in a year is

12,483$ (60$ × 365 × 57% = 12,483$)

the monthly amount of the survivors benefits pension is 520.1$ (12,483$ × 50% ÷ 12 = 520.1$)

*In the above case, the 10,950$ and 520.1$ is awarded at the first month, and then, 520.1$ would be awarded every month after that.

52



Beneficiaries of the Survivors PensionBeneficiaries of the Survivors Pension

• husband, children, parents, grandchildren, brothers or sisters who have disability of grade 3 or higher.55

4 4

33

2

11 • The highest priority is on the wife(including a person in a di facto marital relationship) supported by the employee at that time of his death.

• husband, parents, grandparents who are aged 60 or older.

• children or grandchildren younger than 18

• brothers and sisters younger than 18, or aged 60 or older

66• Fetus at the time of the death of employee(acquires the right to the survivor benefits upon its birth).

53



Lump sum payment of the differentialLump sum payment of the differential

the differential would be paid to the other survival family.

the person who had the person who had received survivor pensionreceived survivor pension

as the highest prioras the highest prior beneficiary dies beneficiary dies

or is remarriedor is remarried with other person,with other person,

no other next no other next prior beneficiariesprior beneficiaries

of survivors of survivors pension, pension, and if all and if all

of 3 conditions of 3 conditions are satisfiedare satisfied

there is a difference there is a difference in the amount between in the amount between

pension so far paid pension so far paid and the amount of and the amount of

survivorssurvivors benefits in lump sum. benefits in lump sum.

54



11 The person who claims survivors pension should send an application form for it, along with a copy of death certificate, a copy of the family register, a copy of the resident registration card also.

22If the person who claims survivor pension and the dead employee are foreigner, a copy of the passport, a copy of the marriage certificate, and other helpful documents issued by his own government to make sure they are same family may be needed.

33 the number of person who has taken care of the beneficiary is limited to only one per beneficiary.

Claims processClaims process

Application Form for Survivors Benefits

56




Survivors Benefits

Funeral Expenses


Nursing Benefits






- 120 days’ worth of the average wage- 120 days’ worth of the average wageFuneral expenses

Funeral expenses

- paid to the person who actually did go through the funeral service

- paid to the person who actually did go through the funeral service

Funeral ExpensesFuneral Expenses

58




Survivors Benefits

Funeral Expenses


Nursing Benefits



59

Injury-Disease Compensation Injury-Disease Compensation AnnuityAnnuity


The Injury-Disease Compensation Annuity is awarded to an insured employee who has not recovered from a work-related injury or sickness even after 2 years of medical care and requires a prolonged period of medical treatment.

DefinitionDefinition

This type of benefit is given in lieu of and at a higher rate than Temporary Disability Benefits, in order to ensure that the injured or sick employee and his dependents can make a stable living.

60



Conditions to benefits entitlementConditions to benefits entitlement

It is necessary that 2 years have passed since the first medical care started, and it is still provided to the injured.

The injured employee have not recovered from his work-related disease.

The final condition is the injured employee should be proved to have

an Invalidity Grade from 1~3.

61



※ Invalidity Grade ※ Invalidity Grade

Invalidity is the state of being unable to look after yourself because of injury or illness, and Invalidity Grade 1~3 is the state of losing 100% labor capability.

What is important in this Injury-Disease Compensation Annuity is the fact that even after 2 years of medical care, an employee has not recovered from disease, and his health condition still needs medical care continuously, and he lost 100% labor ability so, his condition needs to be relevant to the Invalidity Grade 1~3.

In case Even there is an employee with medical care over 2 years, if his condition is not relevant to invalidity grade 1~3, then, he can not get this Injury-Disease Compensation Annuity, so, he will go on with Temporary Disability Benefits.

62



ClaimantClaimant

the insured employee The person who can claims this Injury-Disease Compensation Annuity is the insured employee himself

When 2 years have passed from the date the medical treatment for the work-related injury or disease began and the invalidity grade is determined.

Timing for claimsTiming for claims

63



Claims processClaims process

4

3

2

1

he may fill out and submit to the COMWEL an application form within 14 days from the day he got an Invalidity Grade

The application form should be submitted to the COMWEL regional headquarters or branch office with jurisdiction over the hospital that provide him with medical care treatment.

awarded automatically, until his health conditi

on would be better and no longer is it within the Invalidity Grade 1~3.

the person who wants to get this annuity should get an Inval

idity Grade 1~3

64



Effects of the payment of I.D.C.AEffects of the payment of I.D.C.A

텍스트

텍스트

Once you get an I.D.C.A., the entitlement to Temporary Disability Benefits is terminated.

1

In case, an employee continues to receive Injury-Disease Compensation Annuity even after 3 years have passed since the first medical care started, it shall be deemed as if the employee has been paid lump sum compensation.

2

65



Low-income workers

100/70 of MWis considered as

DAW(in case DWA < 100/70 of MW or no wage subject)

T.D.B

or

application of 100/70 of MW

as DWA

#DAW=Daily Average Wage#MSAC=Minimum Standard Amount of Compensation In case of 2009, it is 46,933 won per day ($39)# MW=Minimum Wage In case of 2009, minimum wage is 32,000 won per day ($2.6)

The Aged Workers

Getting paid 4% decreased

IDCA per year from the age of

61 to 65(-4% -> -20%)

During Additional Medical Care

66




Survivors Benefits

Funeral Expenses


Nursing Benefits



67

Vocational Rehabilitation Vocational Rehabilitation BenefitsBenefits




annuities was made

Vocational training allowances & Vocational

training cost

#Disability grades 1~9#Aged under 60

#Unemployed as of request

#Period : less than 12 months

#Allowance : Minimum wage

#Attendance rate >=80%

Work Adaptation Training Costs

Rehabilitation Exercise Costs

Types and Requirement

Return-to-work subsidy

# Disability grades 1~9 #Employer retains for more than 6 months

# Period : less than 12 months

#Amount : monthly 600,000won($500) for

Disability grades 1~3 and 450,000won($375) for Disability grades 4~9

#Disability grades 1~9#Conducted within 6 months after medical

care and retain hiring for more than 6 months#Period : less than 3

months#Costs is within

450,000won($375) per month

#Disability grades 1~9#Conducted within 6 months after medical

care and retain hiring for more than 6 months#Period : less than 3

months#Costs is within

150,000won($125) per month

- 2008- 2008

Insufficiency for the prevention of insurance fraud

2009-20102009-2010

Vitalization of insurance investigation

20112011

Specialization of insurance investigation

It was established insurance investigation team on 1 JAN 2009 in order to actively and systemically cope with increasing number of insurance fraud in EII.

Road MapRoad Map

33 Insurance Fraud and Its Preventive Effort

Tip-off (information) / recognition

Basic investigation : fraud or not

Detailed investigation by visiting

Report to the prosecution / self-termination

11 22 4433


Process of InvestigationProcess of Investigation

70


The Type of Insurance Fraud in WCI

◦ Deliberate claim for benefits for work-unrelated accidents

◦ Deliberate claim for benefits by non-workers

◦ Deliberate claim for benefits using the insurance of other employers by whom an injured workers are not hired

◦ Submitting incredibly exaggerated medical opinions or salary roll at the request for benefits

◦ Doctors' deliberate claim for medical benefits for undue treatment or malpractice

◦ Deliberate receipt of survivors or permanent disability benefits even after claimant’s death

71


Collection of Undue Gains

◦ When the person has received insurance benefits in a false or other fraudulent ways.

-> In above case COMWEL collects an amount equivalent to double the benefits.

◦ For the other undue gains, COMWEL collects an amount equivalent to the benefits.

-> In above case, if the payment of insurance benefits is based on false reporting, diagnosis or certification by an insurance subscriber, WCI-related medical institution or by a vocational training institution, the insurance subscriber, WCI-related medical institution or vocational training institution shall be held jointly responsible.

72


Appropriation of Insurance Benefits

◦ COMWEL, if there are any insurance benefits, medical expenses or medicine expenses it has to pay to a person who has taken undue gains or an insurance subscriber or an WCI-related medical institution held jointly responsible, may appropriate them to the amount to be collected.

-> Maximum appropriation limit shall be 1/10 of the insurance benefits to be paid.

-> Maximum appropriation limit shall be the insurance benefits to be paid if a person with undue gains responsibility is an insurance subscriber.

-> Maximum appropriation limit shall be the amount equivalent to the medical expenses if there is any medical expenses to be paid to an WCI-related medical institution.

73


The status of Insurance fraud investigation in 2010- As of 30 SEP 2010

SUM

Informer’s report casePlanned or Joint Investigationsu

mAdmitting to charge

Not guilty

Under investigation

264261

53 47 1613

(under investigation)

Uncovered Fraudulent Gains(JAN ~ SEP 2010)

Uncovered Fraudulent Gains in 2009

SUM 7,498,000,000 2,500,000,000

Informer’s report case

6,082,000,000

Planned Investigation 1,416,000,000

Mange the cash reward system for the report on undue gain Mange the cash reward system for the report on undue gainReward system

Reward system

Report the case to the media / press Report the case to the media / press MediaMedia

Print and distribute the advertisement poster on the cases Print and distribute the advertisement poster on the casesDistributionDistribution


Other Preventive EffortsOther Preventive Efforts

44 Discussion Topics

There has been much criticism of the inefficiency of public bodies and the potential benefits of allowing private firms to participate in some of public functions. Although numerous studies have been conducted on the relative performance of the public and private sector for providing a number of services, there has been little relevant study in the field of Workers’ Compensation(WC). Also WC system has somewhat different rationale from other public services. Its operations are complex and there is an enormous variety of cases to be adjudicated consistently, so substantial effort will be required before a government could ensure that the intended policies were being followed. Thus it is necessary to determine whether or not privatization in WC is only an answer to the reform of WC system.

What is your opinion on the above topic?

[The End]

benefits system & preventive measures against insurance fraud workers’ compensation insurance...

Documents

permanent disability

rehabilitation benefit1

number of beneficiary1

contents type of benefits

medical care benefit800

medical care benefit763

preventive effort

funeral expenses22