Insurance Proceeds Dispute | Judgment on Whether a Physician's Medical Treatment Caused Loss to the Insurer

This is a case in which the issue was whether a physician's medical treatment constituted a tort that induced the receipt of indemnity insurance benefits within an insurance proceeds dispute.

The plaintiff is an insurer that provides indemnity insurance, and the defendant is a physician who operates a surgical clinic.

The insured persons in this case received radiofrequency ablation at the clinic operated by the defendant, a procedure that removes thyroid nodules by inserting a needle into the interior of a thyroid tumor and emitting radiofrequency waves to necrotize the tumor. After paying the treatment fees to the defendant, they received insurance benefits equivalent to indemnity medical expenses from the plaintiff.

The plaintiff filed this lawsuit seeking damages, claiming that the defendant, for the purpose of obtaining profit, committed a tort by performing unnecessary procedures on the insured persons in this case and having them undergo even inpatient treatment, thereby inducing or aiding them in receiving indemnity insurance benefits from the plaintiff.

The issues in this case were ▲whether a tort by the defendant existed and ▲the occurrence of loss and causation.

In connection with the insurance proceeds dispute, the court dismissed the plaintiff's claim for the following reasons, upheld the judgment of the first instance ordering the plaintiff to bear the litigation costs as it stood, and dismissed the plaintiff's appeal.

The court determined that, because the insured persons in this case had family members who had suffered from thyroid cancer, the possibility could not be ruled out that such subjective circumstances influenced the relevant insured persons' decision to undergo the procedure.

In light of the circumstances described above, the court found that the fact that the defendant performed radiofrequency ablation in accordance with the subjective symptoms complained of by the insured persons in this case, who were patients, or in accordance with the patients' wishes, could not be taken to conclusively establish that the defendant committed a tort against the plaintiff, an insurer.

In this insurance proceeds dispute case, one of the principal issues was proving that the medical practitioner provided medical services to the patients according to his own subjective judgment.

Medical practitioners and the heads of medical institutions have a duty to provide patients with the best possible care, and under the Medical Service Act they bear the obligation to “strive to improve the quality of medical care, prevent healthcare-associated infections, advance medical technology, and provide patients with the best possible medical services.”

In addition, the plaintiff insurer bore the burden of proving “the physician's tort against the insurer and the occurrence of loss.” However, the plaintiff failed to prove that the relevant procedures had a direct causal relationship with the payment of the insurance benefits.

As this shows, in medical insurance proceeds dispute cases, it should be kept in mind that, for a claim for damages arising from a tort, the requirements of a wrongful act, the occurrence of loss, and causation must all be satisfied.

Daeryun Law Firm LLP provides tailored response strategies for insurance proceeds disputes in the medical field through the collaboration of 🔗attorneys experienced in civil matters and 🔗attorneys experienced in medical matters who have handled numerous medical litigation and medical arbitration cases.