Heung Life Insurance Co., Ltd. (Law Firm Song-tae, Attorney Park Jong-soo, Counsel for the defendant-appellant)

Defendant (Public-service advocate, Counsel for the defendant-appellant)

April 12, 2012

Suwon District Court Decision 2010Da37731 Decided April 7, 2011

1. Revocation of a judgment of the first instance;

2. The plaintiff's claim is dismissed.

3. All costs of the lawsuit shall be borne by the Plaintiff.

1. Purport of claim

With respect to the Defendant’s “oper Mascopic”, it is confirmed that there is no obligation to pay the Plaintiff’s 9th illness surgery benefits based on the insurance contract indicated in the attached list against the Defendant.

2. Purport of appeal

It is identical to the text of paragraphs 1 and 2.

1. Basic facts

A. On July 11, 2003, the Defendant entered into an insurance contract of the “Life Insurance Class II” in the attached list, including the Plaintiff and the General Agreement for Cancer, the Special Agreement for the Guarantee of Specific Diseases, and the Special Agreement for the Guarantee of Operation (hereinafter “instant insurance contract”).

B. Among the terms and conditions of the above special agreement on the guarantee of specific diseases (hereinafter “the terms and conditions of the special agreement on the guarantee of specific diseases of this case”), the major contents pertaining to the nine diseases operating allowances are as follows.

Article 9 Definition and Determination of Specific Diseases

1. In this Special Agreement, the terms “second-class disease”, “nine-class disease” and “first-class disease” mean the following diseases in the basic classification of the fourth Korean Standard Disease Death Classification:

2. The term “nine-class diseases” means diseases classified as urology, heart disease, high blood pressure, cerebrovascular disease, transboundary disease, chronic smoking disease, thystrophalopic disease, thysphalopic disease, Athalopic disorder, and thalopic disease (see attached Table 3’s Schedule 3).

Article 12 Types and Payment Grounds of Insurance Money

If any of the following events occurs to the insured during the insurance period of this special agreement, the Company shall pay the insurance money agreed upon to the beneficiary (see attached Table 1, e.g., attached hereto):

3. Where the insured is diagnosed and confirmed as a nine-class disease after the date of commencement of responsibility for the insured during the insurance period, and he/she undergoes an operation for the purpose of medical treatment for such nine-class disease: Allowances for surgery for the nine-class disease;

Article 13 Detailed Regulations concerning Payment of Insurance Proceeds

(2) In the case of subparagraphs 2 and 3 of Article 12 (Types and Grounds for Payment of Insurance Money), the operation of the 9th illness and specific disease shall be limited to the case of surgery accompanied by hospitalization.

(Attached 1) Schedule of the Payment of Insurance Proceeds

Benefit Name: 9th Medical Care Allowances (Article 12 subparag. 3 of the Terms and Conditions)

Grounds for payment: When the insured undergoes an operation accompanied by hospitalization for a direct purpose during the period of insurance;

Amount paid: (The amount paid once a surgery) three million won.

(attached Table 3) Classification table of 9 Major Diseases

The diseases classified as nine diseases under Article 9 of the Terms and Conditions refer to the following diseases among the Korean Standard Industrial Disease Classification (Enforcement Decree No. 2002-1, January 1, 2003 of the Statistics Korea Notice No. 2002-1, January 1, 2003) revised as the fourth. However, in the Korean Standard Industrial Disease Classification after the fifth amendment, if there is a disease other than the following diseases, it shall be deemed that the disease is included in the terms and conditions:

Curinology:

Disease: Zincilology

Classification Number: E10-E14

C. The insurance policy issued to the Defendant at the time of the conclusion of the instant insurance contract indicated as follows: “The operating allowance for the nine diseases: the amount of guarantee for the nine diseases (one time of surgery) at the time of surgery for the treatment of the nine diseases (3,00,000 won).”

D. The Defendant was diagnosed with urology and hospitalized at ○ Hospital for 21 days from July 27, 2006 to August 16, 2006. The Defendant claimed insurance money from the Plaintiff, and received insurance money for 18 days except for 3 days.

E. On May 11, 2007, and August 23, 2007, the Defendant received an early malphaneization and an artificial insemination inculmatization with the combined lebane and urine urology, and the Plaintiff asked the Plaintiff whether the said surgery would be eligible for the 9th surgery’s benefits, and the Plaintiff paid the surgery insurance proceeds.

F. From September 28, 2007, the Defendant applied for the payment of insurance proceeds for the treatment of rash and injection simultaneously, and the Plaintiff paid the insurance proceeds of KRW 16 million. Since then, the Plaintiff demanded the return of the insurance proceeds paid for 12 million since rash surgery does not fall under the cause for the payment of insurance proceeds. The Defendant asked that rashosis surgery is subject to the payment of the insurance proceeds for 10,000 won paid for 10,000 won since rashosis surgery constitutes the cause for the payment of the operating benefits. After that, the Defendant received from the Plaintiff the payment of KRW 57,000,000 for 19 times in total as to rashosis surgery by October 209.

G. During that period, the Plaintiff’s defect in the claim for insurance money against Raban, which the Defendant implemented on October 15, 2009, did not constitute the ground for the payment of insurance money under the terms and conditions. Upon filing an application for dispute mediation with the Financial Supervisory Commission on October 23, 2009, the Plaintiff would be paid the full amount of the insurance money upon the withdrawal of the application. The Defendant submitted a written withdrawal on December 17, 2009, and the Plaintiff paid the insurance money unpaid on December 18, 2009.

[Ground for Recognition: Facts without dispute, Gap evidence 1 through 4, entry of Eul evidence 2 through 9, purport of whole pleadings]

2. The parties' assertion

A. The plaintiff's assertion

According to the terms and conditions of the instant specific disease security agreement, the grounds for the payment of the training allowances for the 9th illness are limited to “when he/she undergoes a surgery accompanied by hospitalization for the direct purpose of treatment for the 9th disease.” The Defendant’s racer’s opic surgery for the purpose of treatment for the urine urine urology, which cannot be deemed to be an operation for the purpose of direct treatment of the urine urology, and the Plaintiff’s obligation to pay the training allowances for the 9th disease does not exist, since it is not an operation accompanied by hospitalization.

B. Defendant’s assertion

At the time of the conclusion of the instant insurance contract, the Plaintiff merely provided a mere explanation that it would guarantee the 9th urine disease, and there was no explanation that it constitutes the cause of payment of the 9th urine disease surgery benefits only when he/she undergoes a surgery accompanied by hospitalization for the direct purpose of treatment of the 9th urine disease. In addition, Article 13(2) of the Clause of the instant Specific Disease Guarantee Clause which provides that the surgery benefits shall be paid only when he/she undergoes a surgery accompanied by hospitalization violates Article 6 of the Act on the Regulation of Terms and Conditions and thus null and void. The surgery for the treatment of urology includes radic urology for the treatment of urine disease patients. The Plaintiff is aware that radic ur ur ur ur urine was trusted or was subject to the cause of payment, and thus seeking the confirmation of the existence of the obligation is contrary to the doctrine of Fur.

3. Determination

(a) Whether the surgery, which is subject to the payment of an operating benefit, is limited to the number of alcohol accompanying hospitalization;

1) Whether the contract is subject to the duty to explain

Whether Article 13(2) and attached Table 1 of the Clause of the Special Agreement on the Guarantee of Specific Diseases limited to the "the surgery accompanied by hospitalization", which is subject to the payment of the 9th infectious disease surgery benefits, are subject to the obligation to explain under Article 638-3(1) of the Commercial Act (hereinafter referred to as the "limited provision of the instant hospitalization surgery").

The insurer and the persons engaged in the conclusion or solicitation of insurance contracts are obligated to specify and explain the important contents of the insurance contract, such as the contents of the insurance contract, the insurance premium rate system, and changes in the entries in the written subscription for insurance, which are contained in the terms and conditions of the insurance contract. Thus, if the insurer concludes the insurance contract in violation of the duty to specify and explain such terms and conditions, it cannot claim the contents of the terms and conditions as the contents of the insurance contract. However, even if the terms and conditions are stipulated in the terms and conditions, if the matters are general and common in the transaction, which could sufficiently be anticipated for the policyholder without any separate explanation, or are merely merely about the degree that the policyholder would have returned or neglected to what is stipulated in the Acts and subordinate statutes, it cannot be said that the insurer has the duty to specify and explain such matters (see, e.g., Supreme Court Decision 2006Da874

① The limitation clause on the instant hospitalization is a provision that limits the scope of the surgery's payment, ② it does not mean that the surgery is accompanied by hospitalization under normal language law. Therefore, it is difficult for an insurance contractor to limit the number of surgery accompanying hospitalization at the time of entering into a contract. On the other hand, it cannot be deemed that the insurance contractor could have sufficiently predicted without a separate explanation. It is not a matter that is already determined by the law, ③ the degree of insurance products is different depending on the content of the insurance contract, ③ the insurance contract of this case is likely to affect the insurance contractor in choosing whether to enter into an insurance contract and the terms and conditions of the contract. ④ The insurance contract of this case only stated the surgery's payment in the time of the surgery for treating the nine diseases, and it constitutes the subject of the limitation clause in light of the fact that there is no provision on the limitation on hospitalization in this case, and thus, it is possible to mislead the insurance contractor to be paid a hospital regardless of whether to enter into an insurance contract or not.

2) Whether the Plaintiff fulfilled its duty to explain

In the subscription form of the insurance contract (Evidence A) of this case, there is a printed phrase that “the insurance clauses, the example of individual cancellation refund money, and the subscription form for keeping the subscriber was received, and received information on the important contents of the terms and conditions,” and the fact that the Defendant signed the subscription form is recognized.

However, the insurance policy did not state the content of the limited provision on the instant hospitalization, and the fact that the Defendant asked Raber’s Raber’s Macer’s Macer’s Macer’s Macer’s Macer’s Macer’s Macer’s Macer’s Macer’s 19 times, and the Plaintiff paid KRW 57 million over 19 times. In light of these facts and the purport of the entire argument, it can be inferred that the Plaintiff did not explain the limited provision on the instant hospitalization at the time

3) Therefore, the Plaintiff cannot claim the limited provision of the instant hospitalization surgery as the content of the instant insurance contract without a specific and detailed explanation at the time of entering into the instant insurance contract.

(b) Whether the rasher's opic ops are eligible for a surgery benefit;

1) As long as the Plaintiff cannot claim the limited provision of the instant hospitalization surgery as the content of the instant insurance contract, it should be deemed that the 9th illness surgery benefit is paid “when he/she undergoes surgery with the direct purpose of treatment of the 9th disease.”

2) Curinology is classified into E10 (E10 urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine urine and eur 14 (urine urine urine urine urine urine urine urine urine urine urine urine).

① As to the fact-finding of this court, the Korean Medical Association sent a reply that the Korean Medical Association should classify urology into a specific disease of urology; ② urology itself is very difficult to treat urology itself; ③ surgery for the purpose of treatment of urology itself is excessively limited if urology itself is viewed as an surgery for which urology is entitled to surgery benefits; ③ It is against the concept and expectation of the general public who entered into an insurance contract; ④ The Plaintiff also provided that urology urology in the case of urology urology urology urology, urology urology, urology urology urology, urology urology urology, and urology urology urology urology urology eurology eurology eurology eurology eurology eurology eurology eurology eurology eurology eurology eurology eurology eurology eurology eurology eurology.

Therefore, urology accompanied by a urology certificate constitutes urology under the terms and conditions of the instant specific disease security agreement and surgery for the direct purpose of treatment of urology certificate constitutes urology for the purpose of treatment of urology.

3) Furthermore, the terms and conditions of the instant specific disease guarantee agreement did not separate the definition of alcohol (for example, the definition of “accomponing to the human body” or “accomponing to the human body,” etc.). As to the fact inquiry by the court, the Korean Medical Association sent the fact-finding inquiry that the racinary cinary cinary cinology constitutes the direct treatment of hercinary cinary cinology and the surgery for the direct treatment of hercinary cinology. In full view of this, racin cin c

4) Ultimately, Rabdoer’s Rabre surgery is performed for the purpose of directly treating the 9th disease. Accordingly, it constitutes eligible for the payment of 9th disease surgery benefits under the instant specific disease security agreement. Therefore, the Plaintiff’s claim seeking confirmation of the absence of the obligation to pay 9th disease surgery benefits against the Defendant based on the instant insurance contract is without merit.

4. Conclusion

Therefore, the plaintiff's claim of this case shall be dismissed as it is without merit, and the judgment of the court of first instance with different conclusions is unfair, and the plaintiff's claim shall be dismissed. It is so decided as per Disposition.

[Attachment List omitted]

Judges Park Jin-hee (Presiding Judge)