[1] In a case where an insurance company paid medical fees without filing a request for review under Article 19(1) of the former Guarantee of Automobile Accident Compensation Act as to the review result of the Health Insurance Review and Assessment Service, whether it is possible to claim the return of the amount paid to the medical institution (negative in principle), and whether the same applies to medical fees not included in the scope of recognition of motor vehicle insurance medical fees

[2] Validity of the review of and objection to the Motor Vehicle Insurance Medical Fee Review Council

[3] The validity of the review results of the Health Insurance Review and Assessment Service and whether the review results or the review results are legally binding where the review results or the review results change the medical fees for which the Health Insurance Review and Assessment Service became final and notify the parties

[1] Articles 12-2(1) and (2), 19(1) and (3) of the former Guarantee of Automobile Accident Compensation Act (Amended by Act No. 12987, Jan. 6, 2015); Article 11-2 of the former Enforcement Decree of the Guarantee of Automobile Accident Compensation Act (Amended by Presidential Decree No. 25149, Feb. 5, 2014) / [2] Article 21(2) of the former Guarantee of Automobile Accident Compensation Act (Amended by Act No. 12987, Jan. 6, 2015) / [3] Article 19(1) and (3) of the former Guarantee of Automobile Accident Compensation Act (Amended by Act No. 12987, Jan. 6, 2015)

[1] Supreme Court Decision 2012Da88945 Decided March 20, 2015 (Gong2015Sang, 589) / [2] Supreme Court Decision 2008Da41574, 41581 Decided October 23, 2008 (Gong2008Ha, 1594)

more cases insurance Co., Ltd.

Defendant (Attorney Min-sik et al., Counsel for defendant-appellant)

Seoul Central District Court Decision 2017Na23744 Decided September 7, 2017

The judgment below is reversed, and the case is remanded to the Seoul Central District Court.

The grounds of appeal are examined.

1. Article 12-2 (1) of the former Guarantee of Automobile Accident Compensation Act (amended by Act No. 12987, Jan. 6, 2015; hereinafter “The Automobile Accident Compensation Act”) provides that “an insurance company, etc. may entrust a specialized examination institution prescribed by Presidential Decree (hereinafter “specialized examination institution”) with the duties to examine and adjust motor vehicle insurance medical fees claimed by a medical institution pursuant to Article 12 (4).” Article 12-2 (2) of the same Act provides that “The specialized examination institution shall examine whether the motor vehicle insurance medical fees claimed by a medical institution pursuant to paragraph (1) meet the standards for motor vehicle insurance medical fees under Article 15.” Article 19 (1) of the same Act provides that “Where an objection is raised as a result of examination under Article 12-2 (2) of the same Act, the insurance company, etc. and a medical institution may request the Review and Assessment Service for examination within 30 days from the date of notification of the result of examination pursuant to Article 12-12 (2) of the former Enforcement Decree.”

In light of the contents and purport of the aforementioned provisions, an insurance company, etc. notified of the result of review by the Review and Assessment Service pursuant to Article 12-2(2) of the Automobile Loss Act may be deemed to have agreed on the result of review if it did not file a request for review within 30 days from the date it was notified of the result of review by the Review and Assessment Service. Therefore, in cases where the insurance company paid medical fees without filing a request for review as to the result of review by the Review and Assessment Service, barring any special circumstance, it cannot claim for the return of the amount paid to the medical institution on the ground that the claim for payment of medical fees unfairly applied the standard of medical fees covered by automobile insurance. This likewise applies even if it was determined that the medical fees that do not fall under the scope of recognition of the motor vehicle insurance medical fees

Meanwhile, Article 21(2) of the Automobile Loss Act provides that the review decision of the Council shall be deemed to have been agreed upon between the parties in cases where the parties who received the notification of the review decision accept the decision of the Council or do not bring a lawsuit within 30 days from the date of receipt of the notification, and does not provide for the procedure or method of filing a lawsuit. In light of the aforementioned provisions, the above review decision cannot be deemed an administrative disposition in light of the aforementioned provisions, since the parties who received the notification of the review decision of the Council may object to the review decision by filing a lawsuit to the effect that it is incompatible with the contents of the review decision within the period determined by the above Act, and it shall be interpreted that the review decision does not have any legal binding force upon the filing of the lawsuit (see Supreme Court Decision 2008Da41574, 41581, Oct. 23, 2008). However, the Act does not stipulate that the review decision cannot be seen as having changed the contents of the review decision to the parties after the review decision becomes final and conclusive.

2. The lower court acknowledged that the Review Board rendered the instant review and decision on the petition for review of motor vehicle insurance medical fees by the Nonparty, etc. regarding the medical fees of the Defendant, etc., and deemed that all the original Defendant did not raise any objection thereto, and agreed to the review and decision of this case pursuant to Article 19(3) of the Motor Vehicle Loss Compensation Act, and that the Review Board ex officio confirmed and adjusted the review and decision of this case, and notified the recovery of this case. The lower court determined that both the review and decision of the Review Board of this case and the notice of recovery of this case were determined after the review and adjustment of the motor vehicle insurance medical fees claimed by the medical institution upon entrustment by the insurance company, etc. pursuant to Article 12-2 of the Motor Vehicle Loss Compensation Act, etc., and determined that the Plaintiff had a right to claim

3. However, the above determination by the lower court is difficult to accept for the following reasons.

A. According to the reasoning of the lower judgment and the record, around January 7, 2014, the Defendant operating Korea Won filed a claim with the Review Board for review of motor vehicle insurance medical fees with respect to the Nonparty, etc., and the Review Board recognized the full amount of the medical fees claimed by the Defendant as motor vehicle insurance medical fees (hereinafter “instant review and decision”). The Plaintiff, the insurer pursuant to the automobile comprehensive insurance contract with the Nonparty, etc., did not raise any objection to the review and decision, and paid the full amount of the medical expenses to the Defendant on January 1 and 2 of the same year. The Review Board, on July 8, 2014, notified the Defendant of the review results stating that “The Review Board, on the ground that it was not permitted by the relevant statutes, and settled the medical expenses paid for the period during which it was claimed (hereinafter “the instant review and decision”), and sent the Plaintiff a written notification with the same content as the Plaintiff on the 9th day of the same month, and the Defendant rejected the Defendant’s reply to the Review and Assessment Service on July 16, 2014.

B. Examining the above facts in light of the legal principles as seen earlier, the Plaintiff is deemed to have agreed on the review result as the Plaintiff paid medical fees to the Defendant without making a request for review as to the review result of the review of this case by the Review Board, and the claim for the payment was unjustly applied to motor vehicle insurance medical fees, and cannot be claimed for the refund of the amount paid to the Defendant on the ground that the claim for payment was based on the grounds that it did not fall under the scope of recognition of motor vehicle insurance medical fees. The same applies to the case where the Review Board made the instant notice to recover medical fees that became final and conclusive after the formation of the agreement was deemed as lawful. Meanwhile, even if the review decision or the notice to recover medical fees was made between the Defendant and the original Defendant, it cannot be deemed as binding on the original Defendant on the ground that there was no ground under the Motor Vehicle

C. Nevertheless, the lower court determined that the Plaintiff had a claim for the settlement of accounts against the Defendant according to the notice of recovery of this case by the Review Board. In so doing, the lower court erred by misapprehending the legal doctrine regarding the validity of the review results by the Review Board under the Automobile Loss Compensation Act and the establishment of unjust enrichment. The allegation contained in the grounds of appeal on this point is with merit.

4. Therefore, without further proceeding to decide on the remaining grounds of appeal, the lower judgment is reversed, and the case is remanded to the lower court for further proceedings consistent with this Opinion. It is so decided as per Disposition by the assent of all participating Justices on the bench.

Justices Lee Ki-taik (Presiding Justice)