In a case where Party A and Party B entered into a comprehensive automobile insurance contract with respect to automobiles for automobiles, and Party B paid the same amount to Party A after receiving treatment at a hospital operated by Party B due to traffic accident while driving the said automobiles, and Party A received the same amount of money; and Party A filed a petition with the Medical Fee Dispute Resolution Council for review to the Medical Fee Dispute Resolution Council for “A shall refund the above direct payment to Party A”, the case holding that the above review decision was null and void on the ground that the above review decision was without a qualification subject to review.

In a case where Party A and Party B entered into a comprehensive automobile insurance contract for automobiles with respect to automobiles, and Party B paid the same amount to Party A after receiving direct payments from a hospital operating the said automobiles due to traffic accident, and Party A filed a petition for review with the Medical Fee Dispute Resolution Council (hereinafter referred to as the “Council”) to the Medical Fees for Automobile Accident Insurance (hereinafter referred to as the “Council”) and sought reimbursement of direct payments against Party A on the ground that Party A’s request for review was invalid on the ground that: (a) considering the provisions of the Guarantee of Automobile Accident Compensation Act, the request for review with respect to the Council may be made only where the insurance company received a claim for payment of automobile accident compensation from the medical institution; (b) the medical institution did not request for payment of automobile accident compensation fees and received direct payments from the vehicle accident patient; and (c) the examination decision became invalid on the ground that Party A failed to meet the eligibility subject to review.

Articles 12(2) and (5), 19(1), 20(1), and 21(2) of the Guarantee of Automobile Accident Compensation Act

Samsung Fire & Marine Insurance Co., Ltd. (Attorney Jeon Young-young, Counsel for defendant-appellant)

Defendant (Law Firm, Attorneys Kim Jong-hwan et al., Counsel for defendant-appellant)

Cheongju District Court Decision 201Na37241 decided July 3, 2012

January 22, 2013

1. Revocation of the first instance judgment.

2. The plaintiff's claim is dismissed.

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

1. Purport of claim

The defendant shall pay to the plaintiff 5,50,000 won with 5% interest per annum from March 24, 201 to the service date of a copy of the complaint of this case, and 20% interest per annum from the next day to the day of complete payment.

2. Purport of appeal

The same shall apply to the order.

1. Basic facts

The following facts are not disputed between the parties, or may be recognized by comprehensively considering the overall purport of the pleadings in each entry or video set forth in Gap evidence 1 through 8 (including a serial number):

A. The Plaintiff is an insurer who, around January 27, 2009, entered into a comprehensive automobile insurance contract (hereinafter “instant insurance contract”) with Nonparty 1 and (vehicle Nos. 1 omitted) with respect to the instant automobile (hereinafter “instant automobile”) from January 27, 2009 to January 27, 2010.

B. On July 10, 2009, Nonparty 2, the wife of Nonparty 1, caused an accident that fells into the ditch on the right side of the road while driving the instant vehicle on July 10, 2009, and suffered injury, such as a climatic, chest, and scarlete, etc.

C. During the period from November 2, 2009 to December 8, 2009, Nonparty 2 was hospitalized and administered by the Defendant in the department of ○ anesthesia pain medicine operated by the Defendant. Nonparty 2 notified the Defendant of his intention to pay for motor vehicle insurance medical fees, including the amount of KRW 1 million on November 2, 2009, KRW 3 million on November 10, 2009, KRW 3 million on November 10, 2009, KRW 9 million on November 24, 2009, and KRW 9 million on November 24, 2009.

D. However, during the period from December 7, 2009 to December 8, 2009, the Defendant carried out the climatic climatic surgery with Nonparty 2 with respect to Nonparty 2 (hereinafter “instant surgery”), and received 5 million won from Nonparty 2 at the expense of Nonparty 2.

E. On June 3, 2010, Nonparty 2 claimed the Plaintiff for the instant direct payment medical expenses with the insurance money under the instant insurance contract, and on June 28, 2010, the Plaintiff paid KRW 5 million to Nonparty 2.

F. On July 22, 2010, the Plaintiff filed a petition for review with the Medical Fee Dispute Resolution Council (hereinafter “Council”) on the instant medical fee for direct non-payment, and on December 22, 2010, the Council rendered a decision that the Defendant would refund the instant medical fee to the Plaintiff KRW 5 million and bear KRW 550,000 of the review fee (hereinafter “instant decision”).

G. On January 3, 2011, the Plaintiff and the Defendant were notified of each of the instant review and decision and did not raise an objection against the lapse of 30 days thereafter. On March 23, 2011, the Plaintiff paid 50,000 won for review fees to the Deliberative Council.

2. The assertion and judgment

A. The parties' assertion

(1) Summary of the Plaintiff’s assertion

The Defendant is obligated to pay 550,000 won (=500,000 + 550,000 won) to the Plaintiff according to the review and decision of the instant case.

(2) The defendant's argument

According to the Guarantee of Automobile Accident Compensation Act, an insurance company may request a review to the Council only when it receives a claim for motor vehicle insurance medical fees from a medical institution. Since the Defendant did not have filed a claim for motor vehicle insurance medical fees with respect to the instant medical fees, the instant direct non-payment of expenses cannot be subject to review by the Council, and therefore, the review and decision of the instant case shall be

In addition, the instant procedure is not subject to motor vehicle insurance medical fees.

B. Determination

The Guarantee of Automobile Accident Compensation Act provides that the medical institution, which has been notified by an insurance company of the intention to pay for motor vehicle insurance medical fees and the limit of payment, may file a claim for motor vehicle insurance medical fees with the insurance company (Article 12(2)); the insurance company deems that the claim for the payment of motor vehicle insurance medical fees of the medical institution is unfairly applied to the motor vehicle insurance medical fees, the insurance company may file a request for examination with the Council within 60 days from the date on which the claim for the payment of motor vehicle insurance medical fees is filed (Article 19(1)); the Council, upon receipt of such a request from the insurance company, shall review and determine the said request according to the standards for motor vehicle insurance medical fees (Article 20(1)); if the party who has been notified of the said decision is subject to the decision of the Council, it shall be deemed that the agreement has been reached between the parties as of the date following the date on which

Meanwhile, the Guarantee of Automobile Accident Compensation Act prohibits, in principle, a medical institution from claiming for motor vehicle accident patients (including the guardian of a patient; hereinafter the same shall apply) directly claiming for medical expenses equivalent to the medical expenses when it is allowed to file a claim for motor vehicle accident insurance medical fees with the insurance company (Article 12(5) main text), but exceptionally prohibits a motor vehicle accident patient from claiming for relevant medical expenses (the proviso to the same Article).

In full view of the above provisions of the Guarantee of Automobile Accident Compensation Act, a request for review to the Council may be filed when an insurance company has received a claim for the payment of motor vehicle insurance medical fees from a medical institution, and it is reasonable to deem that the Defendant, as a medical institution, did not make a claim for the payment of motor vehicle insurance medical fees concerning the instant medical procedure to the Plaintiff, who is the insurance company, and received the direct non-party 2, the victim of the

Nevertheless, the Plaintiff filed a petition for review with the Council for the examination of the instant medical treatment costs and received the review of the instant case. Therefore, the review of the instant case shall be deemed null and void because it does not meet the qualification for the review.

Therefore, the Plaintiff’s assertion based on the premise that the review of this case is valid is without merit.

3. Conclusion

Thus, the plaintiff's claim of this case is dismissed as it is without merit. However, since the judgment of the first instance is unfair with different conclusions, the judgment of the first instance is revoked, and the plaintiff's claim is dismissed.

Judges Lee Young-chul (Presiding Judge)