Statutes of the Republic of Korea

Article 1 (Purpose)

The purpose of this Decree is to prescribe matters delegated by the Special Act on Prevention of Insurance Fraud and matters necessary for enforcement of the said Act.

Article 2 (Reporting, etc. on Insurance Fraud)

Reporting prescribed in Article 4 of the Special Act on Prevention of Insurance Fraud (hereinafter referred to as the "Act") shall be made in writing, by electronic recording medium, or other means prescribed by the Financial Services Commission in accordance with a format prescribed and announced by the Financial Services Commission, including the following matters:

1.	Name of the relevant insurance company;

2.	Date and place of conduct to be reported;

3.	Persons related to conduct to be reported;

4.	Details of conduct to be reported.

Article 3 (Delay in Payment of Insurance Money and other Grounds)

"Grounds prescribed by Presidential Decree" in Article 5 (2) of the Act means any of the following cases:

1.	Where the terms and conditions of the relevant insurance contract or other statues prescribe that the payment of insurance money shall be delayed or rejected, or the amount of insurance money shall be reduced;

2.

Where justifiable grounds exists to suspect that any of the following conduct committed by a policy holder, etc. prescribed in Article 4 of the Act, constitutes insurance fraud, in the course of an insurance company investigating insurance incident. In such cases, it shall be limited to where the payment of insurance money is delayed:

a.	Where it is reported to the Financial Services Commission pursuant to Article 4 of the Act;

b.	Where a report or a request for investigation is made to the competent investigative agency or other necessary measures are taken pursuant to Article 6 of the Act.

3.

Where an insurance company is found to have committed any of the following conduct in relation to outcomes of investigations of insurance accidents: Provided, That where an insurance company is deemed to file a complaint or request for dispute conciliation for the purpose of unlawfully delaying payment of insurance money or inducing an agreement on reduction of insurance money or abandonment of the insurance claim shall be excluded herefrom:

a.	Where a complaint is filed;

b.	Where a request for dispute conciliation is made pursuant to the Judicial Conciliation of Civil Disputes Act or the Act on the Establishment, etc. of Financial Services Commission.

4.	Other cases prescribed and publicly announced by the Financial Services Commission, where a resonable ground exists for an insurance company to delay or refuse the payment of insurance money, or to reduce the amount of insurance money.

Article 3-2 (Institutions and Organizations Subject to Request for Data and Scope of Data)

(1)	“Institutions and organizations prescribed by Presidential Decree” in the former part of Article 5-3 (1) of the Act means the following institutions and organizations:

1.	The National Health Insurance Service under Article 13 of the National Health Insurance Act and the Health Insurance Review and Assessment Service under Article 62 of that Act;

2.	The National Pension Service established under Article 24 of the National Pension Act;

3.	The Korea Workers' Compensation and Welfare Service under Article 10 of the Industrial Accident Compensation Insurance Act;

4.	The Traffic Accident Compensation Supervisory Service established under Article 39-3 of the Compulsory Motor Vehicle Liability Security Act;

5.	The Korea Transportation Safety Authority established under the Korea Transportation Safety Authority Act;

6.	Other public institutions which hold data prescribed and publicly notified by the Financial Services Commission, among public institutions prescribed in Article 4 of the Act on the Management of Public Institutions.

(2)	The types and scope of data that can be requested to investigate insurance fraudulent acts pursuant to the latter part of Article 5-3 (1) of the Act shall be as follows:

1.	Data on payment of health care benefits under Article 41 of the National Health Insurance Act, data on restrictions on benefits under Article 53 of that Act, and data on collection of unjust enrichment under Article 57 of that Act;

2.

Data on the recovery of disability pensions under subparagraph 2 of Article 49 of the National Pension Act (limited to the recovery of disability pensions on the grounds of Article 57 (1) 1 of that Act), data on the determination of disability grades under Article 67 (4) of that Act, and data on restrictions on benefits under Article 82 of that Act;

3.

Video information on Closed-Circuit Television (CCTV) under subparagraph 1 of Article 52 of the Enforcement Decree of the Road Act, among the information managed through the road traffic information system under Article 60 (1) of that Act in relation to motor vehicle accidents on the road under subparagraph 1 of Article 2 of that Act;

4.

Data on payment of medical care benefits under Article 40 of the Industrial Accident Compensation Insurance Act, data on payment of disability benefits under Article 57 of that Act, data on restrictions on payment of insurance benefits under Article 83 of that Act, and data on collection of unjust enrichment under Article 84 of that Act;

5.	Data on payment of subsidies under Article 50 (5) of the Passenger Transport Service Act;

6.	Data on payment of insurance proceeds and collection of unjust enrichment under Chapter III of the Postal Savings and Insurance Act;

7.	Data on payment of insurance money and mutual aid money of Institutions subject to inspection under Article 39-4 (2) of the Compulsory Motor Vehicle Liability Security Act;

8.	Data processed by taxi operation information management system under Article 13 (1) of the Act on the Development of Taxi Transportation Business;

9.	Other data prescribed and publicly notified by the Financial Services Commission, which are held by the relevant administrative agencies, insurance companies, and institutions and organizations referred to in the subparagraphs of paragraph (1).

(3)	The types and scope of materials that can be requested to investigate an act violating Article 5-2 of the Act pursuant to the latter part of Article 5-3 (2) of the Act shall be as follows:

1.	The records on access to the information and communications network under Article 2 (1) 1 of the Act on Promotion of Information and Communications Network Utilization and Information Protection;

2.	Name, address, and contact Information of users under Article 2 (1) 4 of the Act on Promotion of Information and Communications Network Utilization and Information Protection;

3.	Other information prescribed and publicly notified by the Financial Services Commission as necessary for investigating violations of Article 5-2 of the Act.

[This Article Newly Inserted on Aug. 6, 2024]

Article 3-3 (Standards for Reviewing Propriety of Hospitalization)

(1)

The Health Insurance Review and Assessment Service under Article 62 of the National Health Insurance Act (hereinafter referred to as the "Health Insurance Review and Assessment Service") shall consider the following matters when preparing the standards for reviewing whether hospitalization of policyholders, etc. under Article 4 of the Act is proper (hereinafter referred to as "propriety of hospitalization") pursuant to the former part of Article 7 (3) of the Act:

1.	Individual characteristics of patients, such as medical history, health conditions, etc.;

2.	Effectiveness, necessity, and medical feasibility of hospitalization treatment;

(2)

Where the Health Insurance Review and Assessment Service formulates or changes the standards for reviewing the propriety of hospitalization pursuant to the former part of Article 7 (3) of the Act, it shall publicly announce the details thereof on the website of the Health Insurance Review and Assessment Service.

(3)

Persons prescribed by Presidential Decree, such as investigative agencies in the latter part of Article 7 (3) of the Act means the Chairperson of the Financial Services Commission, the Governor of the Financial Supervisory Service under the Act on the Establishment, etc. of Financial Services Commission (hereinafter referred to as the "Governor of the Financial Supervisory Service"), the Prosecutor General, the Commissioner General of the Korean National Police Agency, and the Commissioner General of the Korea Coast Guard.

[This Article Newly Inserted on Aug. 6, 2024]

Article 3-4 (Obligation to Notify Damage from Motor Vehicle Insurance Fraud)

(1)	Details to be notified by an insurance company to policyholders or the insured pursuant to Article 7-2 of the Act shall include the following matters:

1.

The fact that insurance premiums for automobile insurance (referring to automobile insurance under Article 4 (1) 2 (c) of the Insurance Business Act) have been unfairly increased due to an insurance fraudulent act related to an accident involving a motor vehicle (referring to a motor vehicle defined in subparagraph 1 of Article 2 of the Compulsory Motor Vehicle Liability Security Act Guarantee of Automobile Accident Compensation Act);

2.	Matters concerning the details that the insurance premiums of the motor vehicle insurance policy which has been unfairly increased may be refunded and the procedures for refund thereof;

3.

Where an insurance company discovers that the details of personal information related to a violation of traffic regulations such as drunk driving, etc. or the validity of a driver's license pursuant to Article 176 (10) of the Insurance Business Act for the calculation of insurance premiums are caused by motor vehicle insurance fraud, a statement that the head of an institution possessing the relevant personal information may be notified of the details thereof with the consent of the policyholder and the insured.

(2)	The notification under Article 7-2 of the Act shall be made in writing, by electronic mail, or by mobile phone, etc.

(3)	Except as provided in paragraphs (1) and (2), matters necessary for notification under Article 7-2 of the Act shall be determined and publicly notified by the Financial Services Commission.

[This Article Newly Inserted on Aug. 6, 2024]

Article 4 (Entrustment of Affairs)

Pursuant to Article 13 of the Act, the Financial Services Commission shall entrust the following business affairs to the Governor of the Financial Supervisory Service:

1.	Affairs involving receipt of reports provided in Article 4 of the Act;

2.	Requests for provision of the provision and submission of data under Article 5-3 (1) and (2) of the Act;

3.	Deliberation or requests for correction under Article 5-3 (5) of the Act.

[This Article Wholly Amended on Aug. 6, 2024]

Article 5 (Handling Sensitive Information and Personally Identifiable Information)

(1)

The Financial Services Commission (including persons entrusted with the duties of the Financial Services Commission pursuant to Article 13 of the Act) may handle data containing information on health under Article 23 of the Personal Information Protection Act, information corresponding to criminal history records under subparagraph 2 of Article 18 of the Enforcement Decree of that Act, and information under subparagraph 1-2 (a)(ii) of Article 2 of the Credit Information Use and Protection Act, if it is inevitable to conduct the following affairs:

1.	Affairs involving receipt of reports prescribed in Article 4 of the Act;

2.	Affairs involving requests for provision of the provision and submission of data under Article 5-3 (1) and (2) of the Act;

3.	Affairs involving deliberation or requests for correction under Article 5-3 (5) of the Act;

4.	Affairs on measures, such as accusation prescribed in Article 6 (1) of the Act.

(2)	The Governor of the Financial Supervisory Service may manage data containing personal information in the part of paragraph (1), with the exception of its subparagraphs, where it is inevitable to perform affairs related to measures, such as accusation under Article 6 (1) of the Act.

(3)

Where it is inevitable to conduct affairs concerning reviewing the propriety of hospitalization under Article 7 (2) of the Act, the Health Insurance Review and Assessment Service may handle data containing information on health under Article 23 of the Personal Information Protection Act and information under subparagraph 1-2 (a) (ii) of Article 2 of the Credit Information Use and Protection Act.

[This Article Wholly Amended on Aug. 6, 2024]

Article 6 (Standards for Imposition of Fines for Negligence)

The standards for imposing fines for negligence prescribed in Article 15 (1) of the Act shall be as listed in the attached Table.

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ENFORCEMENT DECREE OF SPECIAL ACT ON PREVENTION OF INSURANCE FRAUD