[1] Whether the requirements for "serious negligence" among the grounds for restricting national health insurance benefits under Article 53 (1) 1 of the National Health Insurance Act should be strictly interpreted and applied (affirmative)

[2] Whether it can be readily determined that an accident constitutes grounds for restrictions on national health insurance benefits under Article 53(1)1 of the National Health Insurance Act merely because a driver caused a traffic accident while driving a motor vehicle in violation of traffic signal (negative), and the standard for determining whether the accident constitutes such grounds (negative)

[1] Article 53(1)1 of the National Health Insurance Act provides that no insurance benefit shall be provided to a person entitled to insurance benefits “where a person causes a criminal act by intention or gross negligence or causes an accident intentionally.” The purpose of the National Health Insurance Act is to contribute to the improvement of national health and the promotion of social security by providing citizens with insurance benefits for the prevention, diagnosis, medical treatment, and rehabilitation of diseases and injury, for childbirth and death, and for the improvement of health (Article 1), and the national health insurance system constitutes the most basic social plan that the national community provides to citizens who are its members. Considering the legislative purpose of the National Health Insurance Act and the characteristics of the national health insurance system, the requirement of “serious negligence” among the grounds for restricting national health insurance benefits ought to be strictly construed and applied.

[2] The proviso of Article 3(2)1 and the proviso of Article 4(1)1 of the Act on Special Cases concerning the Settlement of Traffic Accidents provide that in cases where a driver commits a crime of bodily injury caused by occupational negligence or gross negligence in violation of traffic signal or instruction, a victim may not be punished or a motor vehicle which caused a traffic accident may be prosecuted even if the driver has subscribed to comprehensive motor vehicle insurance, etc. taking into account that it is essential to drive a motor vehicle in daily life, the above provision provides that a driver who has committed a crime of bodily injury caused by occupational negligence or gross negligence shall not be prosecuted in cases where the driver has subscribed to an agreement or comprehensive insurance contract with the victim in order to facilitate prompt recovery of traffic accident damage by inducing the driver to subscribe to the traffic accident. However, in cases of traffic signal violation, the legislative purport of the relevant provision on the Special Cases concerning the Settlement of Traffic Accidents lies in the legislative purport of Article 53(1)1 of the National Health Insurance Act, which is not only in cases where the driver of the motor vehicle commits an accident but also in cases of gross negligence or gross negligence.

[1] Articles 1 and 53(1)1 of the National Health Insurance Act / [2] Article 53(1)1 of the National Health Insurance Act, Article 3(2)1 of the Act on Special Cases concerning the Settlement of Traffic Accidents, and Article 4(1)1 of the same Act

[1] Supreme Court Decision 2002Du12175 Delivered on February 28, 2003

Plaintiff (Attorney Lee Im-soo, Counsel for the plaintiff-appellant)

National Health Insurance Corporation

Seoul High Court Decision 2019Nu65599 decided June 3, 2020

The judgment below is reversed and the case is remanded to Seoul High Court.

The grounds of appeal are examined.

1. Relevant provisions and legal principles

Article 53(1)1 of the National Health Insurance Act provides that no insurance benefit shall be provided to a person entitled to insurance benefits “where a person has caused a criminal act by intention or gross negligence or intentionally caused an accident.” The purpose of the National Health Insurance Act is to contribute to the improvement of national health and the improvement of social security by providing citizens with insurance benefits for the prevention, diagnosis, medical treatment, and rehabilitation of diseases and injury, for childbirth and death, and for the improvement of health (Article 1), and the national health insurance system constitutes the most fundamental social proposal that the State provides to citizens who are its members. Considering the legislative purpose of the National Health Insurance Act and the characteristics of the national health insurance system, the requirement of “serious negligence” among the grounds for restricting national health insurance benefits ought to be strictly construed and applied (see Supreme Court Decision 2002Du12175, Feb. 28, 2003).

Meanwhile, the proviso of Article 3(2)1 of the Act on Special Cases concerning the Settlement of Traffic Accidents and the proviso of Article 4(1)1 of the same Act provide that where a driver commits a crime of bodily injury caused by occupational negligence or gross negligence in violation of traffic signal or instruction, a victim may not be punished or a motor vehicle which caused a traffic accident may be prosecuted even if it purchased comprehensive motor vehicle insurance, etc. taking into account that it is essential for the driver to drive a motor vehicle in daily life, the aforementioned provision provides that a driver who commits a crime of bodily injury caused by occupational negligence or gross negligence shall not be prosecuted if he/she purchases an agreement with the victim or comprehensive insurance policy with the driver to facilitate prompt recovery of traffic accident damage by inducing the driver to subscribe to the traffic accident. However, in cases of traffic signal violation, the legislative purport of the Act on Special Cases concerning the Settlement of Traffic Accidents lies in the legislative purport of Article 53(1)1 of the National Health Insurance Act and the legislative purport of the Act on Special Cases concerning the Settlement of Traffic Accidents as well as in cases where the driver commits an accident falling under any of the proviso of Article 3(1).

2. Determination as to the instant case

According to the reasoning of the judgment below and the record, the Plaintiff violated the stop signal while driving the otobba at the date and place as indicated in the judgment of the court below, and entered the intersection, and attempted to stop the obbba, but the left-hand vehicle pursuant to the new code, but failed to avoid the accident, and received the damaged vehicle and received the accident of this case.

In light of the circumstances of the instant traffic accident, it is difficult to readily conclude that the instant traffic accident and the Plaintiff’s injury therefrom constitute a criminal act due to the “serious negligence,” as it is deemed that there was a negligence on the part of the Plaintiff in violation of the traffic signal, but it cannot be ruled out that the instant traffic accident and the Plaintiff’s injury therefrom were the cause of such criminal act.

Nevertheless, solely based on the circumstances indicated in its holding, the lower court determined that the instant traffic accident and the Plaintiff’s injury therefrom constituted a criminal act caused by “serious negligence.” In so determining, the lower court erred by misapprehending the legal doctrine on restrictions on insurance benefits under the National Health Insurance Act, thereby failing to exhaust all necessary deliberations, thereby adversely affecting the conclusion of the

3. Conclusion

Therefore, without further proceeding to decide on the remainder of the 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

Justices Park Jung-hwa (Presiding Justice)