Claim for Industrial Accident Compensation | A Supreme Court Judgment That Broadly Interpreted the Meaning of “Need for Occasional Nursing Care” in Determining the Disability Grade

This is a case in which the lawfulness of the determination of the disability grade was at issue in connection with a claim for industrial accident compensation.

On February 5, 2020, the plaintiff was diagnosed with “intracerebral hemorrhage, unspecified” as an occupational accident, obtained approval for medical care from the Korea Workers' Compensation and Welfare Service, and completed medical care by April 30, 2021.

The plaintiff subsequently claimed disability benefits, and the Korea Workers' Compensation and Welfare Service issued a disposition determining the plaintiff's disability grade as Grade 3, Item 3.

In response, the plaintiff argued that, in light of the plaintiff's actual disability condition, the disability grade had been underestimated, and filed a lawsuit seeking revocation of the disposition determining the disability grade.

The central issue in this case was whether the plaintiff's neurological disability remained at the level of being “unable to engage in labor for life” or amounted to the level of “requiring occasional nursing care”.

The Supreme Court upheld the lower court's determination as it stood and dismissed the final appeal by the Korea Workers' Compensation and Welfare Service.

The Supreme Court made clear that, under the industrial accident insurance statutes, the disability grade concerning impairment of the nervous system or mental function must be determined by comprehensively considering not only the loss of working ability but also the degree of need for nursing care.

In particular, the Supreme Court held that the meaning of “the daily living activities necessary to sustain life for which occasional nursing care must be received” should not be construed narrowly.

It held that this is not limited merely to physiological acts such as breathing or urination and defecation but also includes cases in which a person cannot independently perform a substantial number of the basic activities repeatedly required to maintain a humane life, such as moving about, eating, dressing and undressing, and personal hygiene.

It also interpreted the meaning of needing nursing care “occasionally” as including cases in which, even if it does not reach a level at which a caregiver must remain on standby at all times, the assistance of others is repeatedly required each time such activities are performed.

In light of this legal principle, it determined that the Korea Workers' Compensation and Welfare Service's disposition treating the plaintiff's disability as Grade 3 was unlawful.

A claim for industrial accident compensation proceeds step by step, from the initial response immediately after an occupational accident occurs, through approval of medical care and determination of the disability grade, to the procedure for contesting a disposition denying approval.

First, when an occupational accident occurs, the worker receives first aid and is transported to a hospital, and at this stage it is important to confirm whether the facility is a medical institution designated for industrial accident insurance.

The injured worker then prepares an application for medical care benefits and submits it to the Korea Workers' Compensation and Welfare Service, and it is also possible to have the application submitted on the worker's behalf through an industrial accident insurance medical institution.

In the application for medical care benefits, the personal details of the injured person, the workplace to which the person belongs, and the circumstances of the accident must be stated and the applicant's seal affixed, and the application must be submitted to the hospital so that a physician's opinion is recorded on the back of the application.

In the case of an occupational disease, the application undergoes deliberation by the Occupational Disease Determination Committee, and the Service ordinarily notifies the worker of whether medical care is approved within seven days after the application is received.

However, where additional investigation into the circumstances of the accident or the causal relationship with the work is necessary, the processing period may be extended as on-site investigations, special medical examinations, and epidemiological investigations are conducted.

If a worker receives a disposition denying approval of medical care, the worker may file a request for review (a Korea-specific pre-litigation administrative remedy, such as a tax objection raised before resorting to the courts) with the Industrial Accident Compensation Insurance Review Committee of the Korea Workers' Compensation and Welfare Service within 90 days from the date on which the worker became aware of the disposition, or may file an administrative lawsuit with the competent administrative court.

In particular, where approval is denied after deliberation by the Occupational Disease Determination Committee, it is possible to file a request for reexamination with the Industrial Accident Compensation Insurance Reexamination Committee or to file an administrative lawsuit directly, without going through the request-for-review procedure.

Because a claim for industrial accident compensation involves complex procedures and specialized determination criteria in this way, it is important to conduct a legal review in parallel from the early stages.