The scope and specific criteria of compensation for occupational diseases in Korea.

The range of diseases covered by workers' compensation is constantly expanding. However, new regulations are required for the recognition of occupational diseases (ODs) because OD types evolve with changes in industrial structures and working conditions. OD criteria are usually based on medical relevance, but they vary depending on the social security system and laws of each country. In addition, the proposed range and extent of work-relatedness vary depending on the socio-economic conditions of each country. The Labor Standards Act (LSA) and the Industrial Accident Compensation Insurance Act (IACIA) of Korea employ lists based on their requirements without listing causes and diseases separately. Despite a considerable reshuffle in 2003, the basic framework has been maintained for 50 yr, and many cases do not fit into the international disease classification system. Since July 1, 2013, Korea has expanded the range of occupational accidents to include occupational cancers and has implemented revised LSA and IACIA enforcement decrees. There have been improvements to OD recognition standards with the inclusion of additional or modified criteria, a revised and improved classification scheme for risk factors and ODs, and so on.

INTRODUCTION

Workers' compensation is a form of social insurance providing wage replacement and medical benefits to employees injured at work. Industrialization spread rapidly across Europe in the 1800s, and in 1838, Germany took the first step to protect injured workers by passing legislation to cover railroad employee accidents. Otto von Bismarck later introduced an Insurance Plan (1881), and in 1884, he enacted a compulsory system of "Sick and Accident Laws," which constitutes the world's first modern workers' compensation system (1).

The development of the workers' compensation system in Korea dates back to 1963, when the first social insurance system called Industrial Accident Compensation Insurance (IACI) was introduced. It is stipulated in the Constitution of Korea that "The State shall endeavor to promote the employment of workers and to guarantee optimum wages through social and economic means and shall enforce a minimum wage system under the conditions as prescribed by the Act" in Article 32 (2), and "Citizens who are incapable of earning a livelihood due to a physical disability, disease, old age, or other reasons shall be protected by the State under the conditions as prescribed by the Act" in Article 34 (3). Labor standard laws (1953) (4) and IACI (1963) (5) laws have been enacted in accordance with the constitution.

International trends in the recognition criteria for occupational diseases

The recognition criteria for occupational diseases (ODs) are based on medical relevance but are formulated within the social security system and laws of each country, and different ranges and levels of work-relatedness are set depending on the prevailing socio-economic conditions.

The International Labor Organization (ILO) has put together a list of ODs by collecting and analyzing the ODs of each country, and the scheme of the OD list proposed in 2010 maintains the mix of logical and systematic classifications proposed in 2002 (6). In addition, the connections between risk factors and the corresponding diseases are not specified, and the risk factors and diseases are listed separately. The causes and diseases not listed in each classification system are covered by a general clause, and this clause provides the guidelines for creating the list of ODs by considering the social consensus, legal situation, and the causes and causal relevance (6).

A historical perspective on workers' compensation in Korea

The IACI Act (IACIA) aims to compensate workers rapidly and fairly for work-related diseases and illnesses by carrying out industrial accident compensation insurance activities, to establish and operate insurance facilities for promoting the rehabilitation of accident victims and their return to society (or to work), and to contribute to worker protection through accident prevention and other projects promoting workers' welfare (4). The "Labor Standards Act (LSA)" stipulates the standards for labor conditions in conformity with the constitution, thereby securing and improving the living standards of workers and achieving well-balanced national economic development (5).

Workers' compensation laws

As the first social insurance system in Korea, IACIA has significantly developed benefits, contents, and claim systems over 50 yr. It has protected injured workers and their families, while evolving into a system that can also cope with the financial burden on employers as well as their responsibilities (7). IACIA came into effect in 1964, but it applied only to workers in mines and large manufacturing industries until July 1, 2000, when it was extended to all workers (Fig. 1) (8,9,10,11,12). The LSA has applied to workers in all types of businesses and companies since 1989, central and local government employees since 2001, and independent contractors since 2008 (13). In 2008, in addition to this extension of coverage, there were significant improvements in the work-related disease compensation approval process, duration of medical care, and rehabilitation programs (14). The LSA and the IACIA of Korea adopted a list based on need, without separate lists for causes and diseases. The LSA does not specify the range of diseases when itemizing risk factors, and the IACIA requires specification of causes and the resulting diseases. However, in practice, agents such as chrome, trichloroethylene, carbon bisulfide, tar, or abnormal air pressure may be singled out as the cause of the disease, but in some, a more complex structure like organic solvents or chemicals, for example, hydrogenated carbon or aromatic compounds may be described. Moreover, the classification of diseases mixes anatomic and systemic categories, as well as causal factors, as in diseases due to certain pathogens, occupational liver diseases, and occupational skin diseases. Despite considerable restructuring in 2003, the basic framework has been maintained for 50 yr, and many cases do not follow the international disease classification system.

Fig. 1

Number of insured workplaces, employees, and industrial disaster victims, and incidence rate of industrial accidents by year.

Criteria for recognition of occupational diseases before the amendments of 2013

The OD criteria in Korea are presented in "The scope of occupational diseases of the Enforcement Decree of LSA (ED-LSA), Schedule 5" and "The specific criteria for the recognition of occupational diseases of the Enforcement Decree of the IACIA (ED-IACIA), Schedule 3". The former ED-LSA consisted of 38 items and focused on categorizing risk factors. Meanwhile, the ED-IACA contained 23 items including a list of risk factors; highly related symptoms, signs, and diseases; and proposed recognition criteria for organs including the brain, cardiovascular system, musculoskeletal system, as well as occupational skin diseases and liver diseases. In fact, it also redundantly proposed the recognition criteria in the ED-IACIA (15). Schedule 3 of the ED-IACIA started with a rule established by the Ministry of Labor in 1982 and proposed recognition standards for six items, namely respiratory diseases, lower back pain, benzene, trichloroethylene, lead, and mercury. A few of the risk factors and diseases were added by 1994, and the rule established in 1995 listed 22 items that were generally similar to the current items in the table of established rules. In 1999, dissecting aortic aneurysm was added to cerebro- or cardiovascular diseases, the standard exposure level for noise-induced deafness was lowered from 90 dB to 85 dB, and the minimum exposure period for recognition was reduced from 5 to 3 yr. The revision of 2000 reduced the minimum exposure period for the recognition of chronic occupational lower back pain from 10 to 5 yr, and the revision of 2003 added liver diseases, occupational skin diseases, and target diseases as consequences of certain risk factors. The revision of 2008 limited occupational cerebro- or cardiovascular diseases to work-related cases, and work-related musculoskeletal diseases were recognized if the existing disease worsened (15). In contrast, the LSA has barely been changed since its establishment. In many cases, the ED-LSA uses comprehensive names rather than proposing specific risk factors and diseases. It employs a few terms that differ from the current ED-IACIA or are excluded from the latter.

The range of diseases covered by workers' compensation and the number of beneficiaries are increasing steadily. However, new regulations are required for the recognition of industrial diseases because many types of industrial accidents result from changes in industrial structures and working conditions. The potential for OD due to new factors is growing, and the types of diseases are changing. In particular, society's interest in occupational cancer, respiratory diseases, and neuropsychiatric diseases has increased, thereby provoking robust discussion on the range of recognized ODs and compensation levels. Consequently, Korea has established new recognition criteria based on an analysis of the problems with the previous specific OD recognition standards and on complementary studies. This study aims to provide a list of risk factors and established causal relationships of ODs, to revise the scope and recognition criteria in the light of domestic exposure conditions, and to specify the criteria and systematize the process of OD recognition in Korea.

MATERIALS AND METHODS

The authors reviewed the scope of ODs in the ED-LSA (13) and the specific OD recognition criteria in the ED-IACIA (15) because these two acts are closely related. The authors excluded diseases due to accidents, and pneumoconiosis, to which special regulations apply. The ILO list of ODs (6) was reviewed in detail, and cases from a few other countries and their OD lists were consulted. For identifying new risk factors and ODs, cases investigated by the Korea Occupational Safety and Health Agency (KOSHA) and the Occupational Lung Diseases Institute of Korea Workers' Compensation and Welfare Service (OLDI of KCOMWL), those recognized as work-related, official domestic exposure status, and the recent scientific literature were reviewed, and opinion was invited from occupational medicine professionals.

RESULTS

Scope and recognition standards for occupational diseases

The risk factors in the ED-IACIA that were not reflected in the LSA, or in cases where different terms were used, were replaced with the latest ones, and the classification of diseases now follows the Korean Version of ICD-10 (KICD-10). The items in the recognition standards specified in Schedule 4 of ED-IACIA that required revision involved the health impact of the chemicals referred to in the old version of the ILO OD. A few issues affecting Korea were resolved, but not others. Although less attention is now needed for cases of exposure to high concentrations of chemicals, prolonged exposure to low concentrations of chemicals, which can cause problems, has emerged as an important issue. The associated lists have been updated by considering relevant cases, recent scientific evidence, and local exposure conditions, and by classifying ODs according to the affected organ system such as respiratory or skin, and as neuropsychiatric diseases and cancer, which have the widest international representation (6). For simplifying the ED-IACIA recognition procedure, it is desirable to provide specific standards of exposure levels, exposure duration, and accumulated exposure to act as definitive standards for approval. However, these are not only based on science but also require social consensus, and there is a possibility that they could be abused as exclusion criteria. Therefore, existing items involving scientific errors are omitted, and cases based on new evidence are added (Tables 1 and 2).

Table 1

Main categories of scope of occupational diseases in Enforcement Decree of the Labor Standards Act, Schedule 5

The specific lists are described in Annexure 1.

Table 2

Main categories of specific criteria for the recognition of occupational diseases in Enforcement Decree of the Industrial Accident Compensation Insurance Act, Schedule 3

The specific lists are described in Annexure 2.

Adding and upgrading risk factors and occupational diseases

The standards for recognition of ODs registered in the IACIA have been revised or expanded in response to social issues. Some ODs such as WMSDs, liver diseases, cancer of the lymphatic or hematopoetic system, cancer due to asbestos, pneumoconiosis, and health disorders due to various chemicals have very specific recognition criteria, but others do not. Therefore, this revision specifies risk factors in a form that meets international standards and increases user convenience (16). The LSA consists of diseases with relatively clear causalities, and chemical, physical, and biological factors with lists of diseases as before. However, it clearly states that the diseases are due to specific risk factors such as chemical factors and disease groups involving respiratory, skin, and musculoskeletal problems (16). The chemical causes include 108 organic chemicals, 19 metals, 8 acids and alkalis, 14 gases, 13 materials that must be licensed for use, and 6 types of dusts containing materials that require a specific medical examination (for workers). The physical features are risk factors requiring a specific medical examination including noise, vibration, radiation, low air pressure, high air pressure, and harmful rays (IR, UV, microwaves, and radio waves). Prior to this revision, the recognition criteria defined only seven carcinogenic factors and were criticized for a lack of standards compared with those of the ILO and other countries (Plan to rationalize recognition criteria for ODs including occupational cancer (17)). Therefore, this analysis establishes a new classification for occupational cancers and includes cases with sufficient evidence of previous exposure and frequent cancers by reviewing carcinogenic materials above IARC group 1, as well as locally recognized examples, with sub-categories for each organ (Tables 1 and 2).

Improvements in the classification schemes for risk factors and occupational diseases

The ILO has analyzed data from 88 countries since 2005 and lists ODs with groupings and classification by agent, target organ system, and occupation; further, many countries follow this scheme (6). Korea applies these standards and adds the social element that stress and work overload are related to the worsening of liver complaints due to the high prevalence of hepatitis. However, redundancy is inevitable in lists that separate causes from the resulting diseases, as suggested by the ILO (6). For example, chemical causes mostly result in respiratory diseases, and skin and nervous diseases are mostly listed under chemical causes and diseases, and some diseases are redundantly listed on the cancer list. Therefore, any information that permits an assessment of the relationship with work and applies to industrial accident insurance for workers diagnosed with a disease, while providing a systematic classification, will increase user convenience. Meanwhile, the classification of risk factors facilitates the development of specific standards, increases their relevance to preventive policies, and enhances user-friendliness because of its familiar structure. Therefore, a redundant proposal system continues to be the most convenient, provided that legal brevity and the system of laws are considered. Further, some may consider that legal brevity is an important factor. Fortunately, the fact that OD regulations in Korea consist of the LSA and the IACIA, and that the ED-IACIA is based on a systematic classification of diseases, while the ED-LSA is based on chemical, physical, and biological factors, ensures integrity of the two laws and establishes a complementary structure (Tables 1 and 2).

Miscellaneous

In addition, the study includes chronic obstructive pulmonary disease, which is on the occupational disease list of the ILO (18) but excluded from similar Korean lists. The recognition standard for cerebro- and cardiovascular diseases is objective because it is based on working hours and clarifies "the consideration whether the degenerative changes are worsened by the work." Moreover, unlike in the past, psychological disturbance due to work is covered under industrial insurance.

DISCUSSION

Korea has expanded the range of ODs including occupational cancers and has implemented the revised ED-LSA and the ED-IACIA, which use a classification system based on diseases, since July 1, 2013. However, despite continuous efforts to provide disaster compensation for workers, a few difficult tasks remain pending. First, the Korea Workers' Compensation and Welfare Service will carefully implement a process to formulate specific recognition conditions before enforcing the new recognition criteria. Various conditions including the presence of the relevant risk factors in the workplace, confirmation of exposure, and presence of the disease process will be proposed specifically. Second, there is a need to establish and operate a permanent committee of the Ministry of Employment and Labor or the Korea Workers' Compensation and Welfare Service that sets recognition criteria reflecting recent opinion regarding a fair society by maintaining consistency of operation and legal stability. Third, there needs to be investment and interest in regulating the recognition criteria on substantive grounds. Finally, Korea has not yet ratified ILO Convention No. 130, which covers the sickness benefits proposed by the Medical Care and Sickness Benefits Convention (1969) (18). This requires that workers receive social welfare including a disabled person's salary, as well as the medical expenses covered by medical insurance for diseases other than ODs. Without a sickness benefit system, social conflict could develop around the recognition of ODs.