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(영문) 서울중앙지방법원 2019.07.10 2018나32677

보험금

Text

1. Revocation of the first instance judgment.

2. The Defendant: (a) KRW 19,600,000 for the Plaintiff and its related expenses from August 1, 2017 to November 3, 2017.

Reasons

1. Facts of recognition;

A. On July 22, 2009, the Plaintiff and the Defendant, an insurance company, agreed to enter into a “C” contract (hereinafter “C”) with the insured as the Plaintiff, and agreed to be subject to the “A” contract with respect to medical expenses for hospitalization of diseases (HII) and the “Special Clause on Security” (hereinafter “Special Clause”).

Article 1 (Compensation for Damages) (1) Where a company receives treatment by hospitalization in a hospital or a clinic (including a herb hospital or herb hospital) due to a disease (excluding a case where the person subject to insurance has received diagnosis or treatment due to the disease within the past five years from the date of subscription for insurance contract) during the insurance period of this special contract entered in an insurance policy (a certificate of subscription for insurance):

1. Hospitalization fees: Medical examination fees, standard sick room usage fees, patient care fees, and food expenses;

2. Expenses for hospitalization: Testing fees, radiation fees, medication and prescription fees, the main feed, medical therapy (physical therapy, rehabilitation treatment), mental therapy, treatment, materials treatment, glocks, and designated medical treatment fees;

3. Expenses for surgery: Expenses for surgery, anesthesia and materials for surgery;

4. Sick difference: The difference between the difference between the actual user's disease room (based on the medical charge for two rooms in cases where the person uses the room, special room, or one person room) and the difference between the sick room and the standard sick room. (5) The company shall compensate the amount equivalent to 50% of the total amount of the expenses under paragraph (1) 1, 2, and 3 (referring to the part of the medical care benefits determined by the National Health Insurance Act and the part of the non-benefit) borne by the insured under the National Health Insurance Act and the expenses under subparagraph 4 within the limit of the compensation limit under this special agreement stated in the insurance policy per accident.

However, if the insured (subject to insurance) is not subject to the national health insurance (including the case of failing to undergo the medical care benefit procedures prescribed in the national health insurance), the amount equivalent to 40% of the total medical expenses for hospitalization of diseases caused by paragraph (1) shall be the insurance policy per one accident.