Restrictions on the payment of national health insurance benefits
Restrictions on the payment of insurance benefits by intention or gross negligence- The National Health Insurance Service (hereinafter referred to as the “NHIS”) does not provide insurance benefits to any of the following persons who are eligible to receive insurance benefits (Article 53 (1) of the “National Health Insurance Act”):
· If he/she has caused criminal conduct by intention or gross negligence or caused an accident by intention
· If he/she has failed to follow health care-related instructions of the NHIS or the health care institution by intention or gross negligence
· If he/she has refused to submit the documents referred to in Article 55 of the “National Health Insurance Act” or other items or evaded questions or medical checkups by intention or gross negligence
· If he/she receives or is eligible to receive insurance benefits or compensations under other statutes due to a disease, injury, or disaster incurred relating to his/her business or in the line of duty
- When a person eligible for insurance benefits has received, from the State or a local government, benefits equivalent to the insurance benefits or expenses equivalent to the costs of insurance benefits under the provisions of other statutes, the NHIS will not provide insurance benefits to the extent of such amount (Article 53 (2) of the “National Health Insurance Act”).
Restrictions on insurance benefits due to insurance premiums in arrears1. If a self-employed insured has not paid the insurance premium imposed on his/her household for one month or longer, the NHIS may not provide insurance benefits for the self-employed insured until the insurance premium in arrears is fully paid. However, if the total number of failure to pay monthly insurance premiums (insurance premiums in arrears which have already been paid will be excluded from the total number of failure, and the period of delinquency in paying insurance premiums will not be taken into consideration) is below six times, or the income and property of the insured and his/her dependents are below the standard prescribed by Presidential Decree, the payment will not be restricted (Article 53 (3) of the “National Health Insurance Act” and Article 26 of the “Enforcement Decree of the National Health Insurance Act”).
2. Notwithstanding the above provision, the insurance benefits may be provided if a self-employed insured has obtained approval for the payment in installment for the insurance premiums in arrears and paid the approved insurance premiums at least once. However, if anyone who has obtained approval for the payment in installment fails to pay the approved insurance premiums five times or more (if the number of installments approved under Article 53 (1) of the “National Health Insurance Act” is less than five times, it means the number of installments) without any justifiable grounds, the NHIS may not provide insurance benefits (Article 53 (5) of the “National Health Insurance Act”).
3. Any insurance benefits received during which insurance benefits are not provided (hereinafter referred to as the “period of restricted benefits”) will be deemed as insurance benefits under the following circumstances only (Article 53 (6) of the “National Health Insurance Act”):
· If the insurance premiums in arrears are fully paid by the due date for its payment in the month to which the date two months lapse from the date when the NHIS has served notice that insurance benefits were received during the period of restricted benefits
· If the insurance premiums for which installment payment is approved are paid at least once by the due date for its payment in the month to which the date two months lapse from the date when the NHIS has served notice that insurance benefits were paid during the period of restricted benefits belongs (however, this will not apply to cases where anyone who has obtained approval for the installment payment fails to pay the approved insurance premiums five times or more without justifiable grounds)
※ If self-employed insured who are overseas Korean nationals and foreign nationals [ excluding those who have the status as permanent resident (F-5) and marriage with Korean citizen (F-6)] defaults on the payment of their insurance premium, the NHIS will be provide insurance benefits from the date of default (refers to the first day of the month following the month to which the due date for payment until the 25th day of the immediately preceding month) until they fully pay the insurance premium in arrears. In this case, proviso to 1., 2. and 3. above will not apply (Article 109 (10) of the “National Health Insurance Act” and Article 9 of the “Application Standards for Overseas Korean Nationals and Foreign Nationals who Stay in Korea for a Long Period of Time”).