산업재해보상보험 요양급여 청구 불승인 원인에 대한 후향적 분석

초록

Objectives: The purpose of this study is to analyze the reasons of the claim rejections and denials compensated by dental related the Industrial Accident Compensation Insurance (IACI) that is operated by the Korea Workers’ Compensation and Welfare Service (COMWEL). Methods: We collected 803 claims from one consultant who responded to dental-related medical inquiries commissioned by the Daegu and Gyeongbuk Workers’ COMWEL from January 2021 to May 2023. We analyzed the approval status and the reasons for non-approval, based on the reviewed response materials and dental online medical consultation data. Results: Among the initial and supplementary compensation applications, there were 79 cases with insufficient examina tions, 72 cases with incomplete records, 19 cases with errors, 148 cases due to pre-existing conditions, and 6 cases where the applicant was ineligible for medical benefits. The reasons for re-evaluation after data supplementation included 122 cases of inadequate examinations, 76 cases of incomplete records, 24 cases with logical errors, 11 cases with insufficient photographs, and 57 cases for a combination of these reasons. Conclusions: In the context of industrial injury compensation claims, the denial of claims often arises from missing or incomplete dental records, diagnostic omissions, or logical inconsistencies between records, diagnoses, and treatment plans. Therefore, it is essential to ensure accurate medical records, appropriate examinations, and evidence-based diagnosis. Spe cial attention should also be given to the collection of clinical data, including photographs.

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