In a case where an insurance company and a medical institution take effect as agreed-upon under Article 19(3) of the Guarantee of Automobile Accident Compensation Act by paying medical expenses following the review results of the Health Insurance Review and Assessment Service to a medical institution, whether the insurance company may seek restitution of unjust enrichment against the victim with respect to the amount equivalent to the amount paid for medical treatment, such as injury not having proximate causal relation with the traffic accident in question, among the above medical expenses (affirmative)

Article 19(3) of the Guarantee of Automobile Accident Compensation Act provides that if an insurance company notified of the results of the review by the Health Insurance Review and Assessment Review Board on the claim for motor vehicle insurance medical fees against an insurance company of a medical institution and a medical institution files a request for review within 30 days from the date the medical institution is notified, the insurance company and the medical institution are deemed to have agreed on the contents

The above legal provision aims to ensure appropriate medical treatment for the victim of traffic accidents by concluding a dispute between an insurance company and a medical institution surrounding motor vehicle insurance medical fees as soon as possible, and not to regulate legal relations between the insurance company and the victim caused by traffic accidents. Therefore, even if the insurance company and the medical institution take the effect of the agreedness principle as stipulated in the above legal provision by paying medical expenses according to the result of the review by the Health Insurance Review and Assessment Service, it is reasonable to deem that the amount equivalent to the money paid by the insurance company for the treatment of injury, etc. whose proximate causal relation with the traffic accident is not recognized among the medical expenses paid by the insurance company to the medical institution, has obtained benefits

Article 741 of the Civil Act, Article 19(3) of the Guarantee of Automobile Accident Compensation Act

Furthermore, the Insurance Co., Ltd. (Attorney Kim Jong-tae, Counsel for defendant-appellant)

Defendant

Daejeon District Court Decision 2017Na111176 Decided December 5, 2018

The part of the judgment of the court below against the plaintiff is reversed, and that part of the case is remanded to the Daejeon District Court Panel Division. The defendant's appeal is dismissed.

The grounds of appeal are examined.

1. As to the Defendant’s ground of appeal

The lower court determined that it is difficult to recognize a proximate causal relation between the symptoms revealed to the Defendant after May 31, 2013 and the instant accident, in light of various circumstances, such as the details of the instant accident that the insured vehicle driven by the Defendant, the degree of shock arising from the instant accident, the details that the Defendant was treated as a complex confeculation arising from the previous traffic accident, the details that the Defendant was treated after the instant accident, and the progress of symptoms.

Examining the relevant legal principles and records, the lower court did not err in its judgment by misapprehending the legal doctrine regarding proximate causal relation, or by exceeding the bounds of the principle of free evaluation of evidence against logical and empirical rules.

2. Plaintiff’s ground of appeal

A. Article 19(3) of the Guarantee of Automobile Accident Compensation Act (hereinafter “The Automobile Accident Compensation Act”) provides that if an insurance company notified of the review results by the Health Insurance Review and Assessment Service concerning claims for motor vehicle insurance medical fees filed by a medical institution, and the medical institution fails to file a review with the Motor Vehicle Insurance Review and Assessment Service within 30 days from the date the medical institution is notified of such review results, the insurance company and the medical institution shall be deemed to have agreed on

The above legal provision aims to ensure appropriate medical treatment for the victim of traffic accidents by concluding a dispute between an insurance company and a medical institution surrounding motor vehicle insurance medical fees as soon as possible, and not to regulate legal relations between the insurance company and the victim caused by traffic accidents. Therefore, even if the insurance company and the medical institution take the effect of the agreedness principle as stipulated in the above legal provision by paying medical expenses according to the result of the review by the Health Insurance Review and Assessment Service, it is reasonable to deem that the amount equivalent to the money paid by the insurance company for the treatment of injury, etc. whose proximate causal relation with the traffic accident is not recognized among the medical expenses paid by the insurance company to the medical institution, has obtained benefits

B. The gist of the lower judgment is as follows: ① There is no proximate causal relation between the instant accident and the damages equivalent to KRW 73,249,720 that was disbursed to the Defendant for the treatment of symptoms revealed to the Defendant after May 31, 2013.

② Therefore, barring any special circumstance, the Defendant, without any legal ground, obtained the benefit of exempting the Plaintiff from the obligation to pay medical expenses equivalent to the above KRW 73,249,720 for medical institutions, and accordingly, has the obligation to return the same amount to the Plaintiff.

③ However, the Plaintiff did not raise an objection to the examination results of the Health Insurance Review and Assessment Review Committee regarding KRW 51,281,490, but did not request the review to the Motor Vehicle Insurance Medical Fee Review Committee, which was again dismissed. If so, the amount equivalent to KRW 51,281,490, which was paid under the agreement on the payment of medical expenses between the Plaintiff and the medical institution based on Article 19(3) of the Automobile Loss Compensation Act, and as a result, even if the Defendant exempted the medical institution from the obligation to pay medical expenses equivalent to KRW 51,281,490, the Defendant cannot be deemed as

C. However, we cannot accept the judgment of the court below as it did not comply with the legal principles as to Article 19 (3) of the Automobile Loss Act. The ground of appeal assigning this error is with merit.

3. Conclusion

Therefore, the part of the lower judgment against the Plaintiff is reversed, and that part of the case is remanded to the lower court for further proceedings consistent with this Opinion. The Defendant’s appeal is dismissed. It is so decided as per Disposition by the assent of all participating Justices on the bench.

Justices Ahn Jae-chul (Presiding Justice)