2020Da234538, Confirmation of the existence of an obligation

2020Da234545 Insurance proceeds

person

Plaintiff (Counterclaim Defendant)

Law Firm LLC et al., Counsel for defendant-appellant

Attorney Lee Dong-name et al.

Defendant 1 and two others

Law Firm Samyang, Counsel for the defendant-appellant

[Defendant-Appellee] Plaintiff 1 and 3 others

Busan District Court Decision 2019Na53266, 2019Na53273 Decided May 20, 2020

(Counterclaim) Judgment

October 15, 2020

The part of the lower judgment against the Plaintiff (Counterclaim Defendant) regarding the main lawsuit and counterclaim shall be reversed, and that part of the case shall be remanded to the Busan District Court.

The grounds of appeal are examined.

1. The details of the instant case and the judgment of the court below

A. The circumstances of the instant case are as follows.

1) 피고(반소원고, 이하 '피고'라고만 한다) 1이 망 소외인(이하 '망인'이라 한다)을 피보험자로 하여 가입한 원고(반소피고, 이하 '원고'라고만 한다)의 실버암보험에 대한 이 사건 보험약관에 의하면, 피보험자가 암보장개시일 이후에 고액암으로 진단확정 받았을 때 고액암진단 보험금을 최초 1회에 한하여 지급하기로 되어 있다(제6조 제1호). 2) 그런데 이 사건 보험약관 제3조는 '[암, 기타 피부암, 갑상선암의 정의 및 진단확정'이라는 제목 하에, 제1항에서 '암'의 의미는 한국표준질병사인분류의 기본분류에서 악성신생물(암)로 분류되는 질병(별표 4)으로서 기타피부암이나 갑상선암, 그리고 전암상태(암으로 변하기 이전의 상태)를 제외한다고 규정하면서, 그와 별도로 제4항에서 '고액암'은 제6차 개정 한국표준질병사인분류의 기본분류에 있어서 악성신생물(암)로 분류되는 질병 중 백혈병, 뇌암, 골수암에서 정한 질병이라고 규정하고 있다. 그리고 제7항에서 암(기타피부암 및 갑상선암 제외)의 '진단확정'은 병리 또는 진단검사의학의 전문의사 자격증을 가진 자에 의하여 내려져야 하고, 이 진단은 조직(fixed tissue)검사, 미세바늘 흡인(fine needle aspiration biopsy)검사 또는 혈액(hemic system) 검사에 대한 현미경 소견을 기초로 하여야 하며, 다만 그러한 진단이 가능하지 않을 때에는 피보험자가 암으로 진단 또는 치료를 받고 있음을 증명할만한 문서화된 기록 또는 증거가 있어야 한다고 규정하고 있다.

3) According to the insurance clauses of this case, the insurance money received when the insured was diagnosed and confirmed as a high-amount cancer after the date of commencement of cancer security is 10 times the insurance money received when the diagnosis was confirmed as a result of the diagnosis of cancer other than a high-amount cancer (except for the crypam cancer, other crypump cancer, site cancer, and boundary cryp cancer), and 10 times the insurance money received when the diagnosis and determination was made as a prone cancer or precoption cancer (Article 6 subparag. 1 and 2, and attached Table 1 of the Standards for Payment of Insurance Money).

4) On March 2017, the Deceased’s results of the pathology test conducted at the Yangsan National University Hospital (Squa) was diagnosed as the fluto cell cancer (Squa), and the results of pathology test conducted at the same hospital around August 2017 as the fluto cell cancer.

Around May 2018, the deceased issued a medical certificate stating name of sick from Einsian medical specialists, who are in charge of the same hospital, such as ‘the highly advanced fluorites (C41)' which falls under the highest fluorites stipulated in the insurance contract of this case. As a result of the medical record appraisal conducted by the court of the first instance on the medical records appraisal conducted by the medical doctor and the professional doctor of the first instance, the appraiser may conflict with the diagnosis name depending on the perspective of 'fluoral clinical doctor and the professional doctor, but from the perspective of Sinsian doctor, the deceased's disease classification cannot be viewed as c41 (the fluoral fluoral fluoral fluoral fluor) on the ground that the deceased's disease is the fluoral fluoral fluoral flu

B. The lower court acknowledged the Plaintiff’s obligation to pay the Plaintiff’s high-amount cancer insurance money to the Defendants, the deceased’s heir. The reason is that (i) Article 3(7) of the insurance clause of the instant case that the deceased’s license should be determined by the doctor with a medical specialist in pathology or diagnosis medicine does not apply to large-amount cancer, and (ii) it constitutes “when the deceased was diagnosed and confirmed by the deceased’s diagnosis and confirmation was made by the deceased’s 'the malicious life (C41)’ from clinical surgery.

2. Regarding ground of appeal No. 1

A. According to the principle of trust and good faith, the insurance terms and conditions should be interpreted fairly and reasonably in consideration of the purpose and purpose of the terms and conditions in question, and should be objectively and uniformly interpreted based on average customer interests, without considering the intended purpose and intent of individual parties to the contract (see, e.g., Supreme Court Decision 2010Da45777, Nov. 25, 2010). The insurance terms and conditions of the insurance contract in this case and the structure of other skin cancer and the remainder of the contract shall be determined by a person who holds a professional doctor's license in medical examination or diagnosis medicine, and it is difficult to view that such determination does not require such determination of insurance money in cases of a large-sum cancer for which a higher amount of insurance money is paid. In light of the above, Article 3(7) of the insurance terms and conditions of the insurance contract in this case should be interpreted as excluded from the determination of the amount of the insurance contract in this case, and thus, it should also be interpreted as 'the amount of the insurance contract in this case' as '.

B. Nevertheless, the lower court determined that Article 3(7) of the insurance clause of this case does not apply to a large-scale cancer without any particular reason, and determined that it may fall under “when it was diagnosed and confirmed as a high-amount cancer, which is the cause for paying the insurance benefit of this case, even if it was not determined by a person with a professional doctor’s license in pathology or diagnostic examiner’s license.” In so doing, the lower court erred by misapprehending the legal doctrine on the interpretation, etc. of the insurance clause of this case. The allegation contained in the grounds of appeal on

3. Regarding ground of appeal No. 2

A. As seen earlier, the diagnosis and confirmation of cancer and high-amount cancer are required to be conducted by a person with a professional doctor’s license in pathology or diagnostic test medicine pursuant to Article 3(7) of the instant insurance terms and conditions: Provided, That this is not only the diagnosis and confirmation by a person with a professional doctor’s license, such as pathology, but also includes the diagnosis based on the results of pathology tests conducted by a clinical doctor who directly conducts the diagnosis and treatment of patients (see, e.g., Supreme Court Decisions 2011Da13968, 13975, May 24, 2012; 2017Da268616, Oct. 12, 2018). However, it is not included in the interpretation of the insurance terms and conditions in light of Article 3(7) of the foregoing.

B. In the instant case, this case’s medical specialist appears not to fall under “a person with a professional doctor’s license for pathology or diagnosis and test medicine” as stipulated in Article 3(7) of the instant insurance contract. Thus, even if a non-humanian medical specialist diagnosed the deceased’s name as a part of the two sides of the two sides of the two sides of the two sides of the disease, it is difficult to view that this case’s insurance contract constitutes a cause for payment of high-amount cancer insurance money as stipulated in the instant insurance contract, and there is no special circumstance to see this differently.

Nevertheless, the lower court determined that the Plaintiff was liable to pay the insurance money on the ground that the high-level cancer, which is the cause for the payment of the insurance money for the high-level cancer diagnosis. In so doing, the lower court erred by misapprehending the legal doctrine on the interpretation of the insurance clause of this case, thereby adversely affecting the conclusion of the judgment. The allegation contained in the

4. Conclusion

Therefore, the part of the judgment of the court below against the plaintiff regarding the main lawsuit and counterclaim is reversed, and that part of the case is remanded to the court below for a new trial and determination. It is so decided as per Disposition by the assent of all participating Justices on the bench.

Supreme Court Decision 201

Justices Kim Jae-in

Justices Min Il-young in charge

Justices Lee Jae-hwan