CONTENTS
- 1. Insurance Benefit Dispute, the Detailed Circumstances?
- - Insurance Benefit Dispute, the Relevant Statutes and Precedents?
- 2. Insurance Benefit Dispute, the Court’s Determination?
- 3. Insurance Benefit Dispute, Daeryun’s Strategy?
1. Insurance Benefit Dispute, the Detailed Circumstances?
In the insurance benefit dispute, the plaintiff A was in a situation where the National Health Insurance Service had imposed a disposition reclaiming unjust enrichment.
While A was riding a motorcycle, A violated a traffic signal and turned left, colliding with the vehicle of a victim who was proceeding straight.
As a result of this accident, A sustained injuries such as an “injury to an unspecified part of the spinal cord” and received treatment at a hospital for about three months. Of the medical expenses incurred during the course of treatment, approximately ten million won was paid by the National Health Insurance Service as an insurance benefit.
The District Court subsequently issued a summary order imposing a fine of 500,000 won on A on the charge of violation of the Act on Special Cases concerning the Settlement of Traffic Accidents (a Korean statute limiting prosecution of traffic-accident offenses where insurance coverage or a settlement applies, with no direct common-law equivalent) (injury), stating that A, “through occupational negligence in turning left despite the straight-ahead signal, struck the victim’s vehicle and caused the victim to suffer an injury requiring about two weeks of treatment.”
Accordingly, the National Health Insurance Service issued a disposition stating that, because this accident occurred through A’s gross negligence arising from the traffic signal violation, it would, pursuant to Article 53 of the former National Health Insurance Act, reclaim as unjust enrichment the full amount of the insurance benefits that the National Health Insurance Service had borne.
A argued, “I collided with the victim’s vehicle due to inexperienced driving while changing lanes on a slippery road,” and “this accident did not occur through a criminal act caused by my gross negligence,” and thereby filed a lawsuit seeking revocation of the disposition reclaiming unjust enrichment against the National Health Insurance Service.
Insurance Benefit Dispute, the Relevant Statutes and Precedents?
National Health Insurance Act
Article 1 (Purpose)
The purpose of this Act is to contribute to the improvement of national health and the promotion of social security by providing insurance benefits for the prevention, diagnosis, treatment, and rehabilitation of citizens’ diseases and injuries, as well as for childbirth, death, and health promotion.
Article 53 (Restriction on Benefits)
(1) The Service shall not provide insurance benefits where a person eligible to receive insurance benefits falls under any of the following subparagraphs.
1. Where the cause lies in a criminal act resulting from intent or gross negligence, or where the person caused the accident intentionally
The national health insurance system constitutes the most basic social safety net that the national community provides to its members, the citizens. Considering the legislative purpose of the National Health Insurance Act and the characteristics of the national health insurance system, among the grounds for restricting national health insurance benefits, the requirement of “gross negligence” should be interpreted and applied as strictly as possible.
- See Supreme Court, Decision of February 28, 2003, 2002 Du 12175, among others
2. Insurance Benefit Dispute, the Court’s Determination?
The District Court, which heard the lawsuit seeking revocation of the disposition reclaiming unjust enrichment in connection with the insurance benefit dispute, emphasized the difference in the interpretation of “gross negligence” between the Act on Special Cases concerning the Settlement of Traffic Accidents and the National Health Insurance Act.
The Act on Special Cases concerning the Settlement of Traffic Accidents is a law that mitigates the criminal liability of drivers when a traffic accident occurs, and where a driver has reached a settlement with the victim or is covered by comprehensive automobile insurance, a special provision applies under which criminal punishment is exempted or no public prosecution is instituted.
However, where an accident is caused by gross negligence such as a traffic signal violation or drunk driving, this falls outside the special provision, and criminal punishment cannot be avoided. In such a case, the law provides that criminal liability may be imposed regardless of whether there is a settlement with the victim or insurance coverage.
By contrast, the National Health Insurance Act is a social security law intended to guarantee the health of citizens, and it provides grounds for restricting insurance benefits, one of which is where an accident is caused by “intent or gross negligence.” Accordingly, the National Health Insurance Service may issue a disposition reclaiming the insurance benefits.
However, under the National Health Insurance Act, “gross negligence” corresponds to a case of substantially violating the duty of care according to generally accepted social norms, and for it to be recognized as gross negligence, there must be a situation in which the driver markedly violated the duty of care even though the driver could easily have avoided the accident.
Taking this into account, the panel, which analyzed the detailed circumstances of the accident, determined that “it can be seen that, at the time of the accident around midnight, on a road surface made slippery by rain, A, as a novice driver lacking the ability to respond to traffic conditions, caused the accident through a momentary error of judgment,” and that “it is difficult to conclude that the cause of this accident lay solely in A’s traffic signal violation.”
Accordingly, the court held that A’s negligence did not amount to gross negligence and that the National Health Insurance Service’s disposition restricting insurance benefits was unlawful.
3. Insurance Benefit Dispute, Daeryun’s Strategy?
In the lawsuit related to the insurance benefit dispute, after causing a traffic accident through a traffic signal violation, the plaintiff was subjected to a disposition by the National Health Insurance Service reclaiming insurance benefits, but the panel held that the plaintiff’s gross negligence was not found and ordered the reclamation disposition to be revoked.
A disposition restricting insurance benefits due to a traffic accident, and in particular the question of whether there was gross negligence, is an issue that is not easily determined.
If you face an unjust disposition or a reclamation of insurance benefits arising from a similar issue, you are welcome to entrust your case to Daeryun Law Firm LLP. We will thoroughly analyze the complex legal issues and assist you with a clear legal response.
