Where a beneficiary of insurance benefits under the National Health Insurance Act has received financial compensation related to the items of insurance benefits from a third party, such as a perpetrator, and then has received insurance benefits under the National Health Insurance Act, the National Health Insurance Corporation may collect unjust enrichment from the beneficiary pursuant to Article 57 of the National Health Insurance Act (=amount equivalent to the ratio of responsibility of

If a beneficiary of insurance benefits under the National Health Insurance Act receives all property compensation related to the items of insurance benefits from a third party, such as a perpetrator, the National Health Insurance Corporation (hereinafter “Corporation”) is exempted from the obligation to pay insurance benefits within the scope of compensation (Article 58(2) of the National Health Insurance Act). In such cases, the scope of expenses that the Service is not obligated to exempt from the obligation to pay insurance benefits is limited to the amount equivalent to the ratio of the perpetrator’s liability among the contributions to the Service, i.e., the amount for which the cause of the perpetrator’s act occurred. Therefore, if a third party’s beneficiary received insurance benefits after compensation for damages, the scope of expenses that the Service is entitled to collect as unjust enrichment

Articles 57 and 58(2) of the National Health Insurance Act

Supreme Court en banc Decision 2018Da287935 Decided March 18, 2021 (Gong2021Sang, 835)

Plaintiff 1 and one other (Attorney Kim Jae-hwan, Counsel for the plaintiff-appellant)

National Health Insurance Corporation

Seoul High Court Decision 2018Nu63961 decided December 13, 2018

The part of the lower judgment against Plaintiff 1 is reversed, and that part of the case is remanded to the Seoul High Court. The appeal by Plaintiff 2 is dismissed. The costs of appeal between Plaintiff 2 and the Defendant are assessed against the said Plaintiff.

The grounds of appeal are examined.

1. Judgment on Plaintiff 2’s grounds of appeal

The lower court determined that the part of Plaintiff 2’s claim in the instant lawsuit was unlawful on the grounds that Plaintiff 2 cannot be deemed as having received legal interests protected by the disposition, rather than the other party to the instant disposition.

Examining the reasoning of the lower judgment in light of the relevant legal principles, the lower judgment did not err by misapprehending the legal doctrine on standing to sue, as alleged in the grounds of appeal

2. Judgment on Plaintiff 1’s grounds of appeal

A. If a beneficiary of insurance benefits under the National Health Insurance Act receives all property damages related to the items of insurance benefits from a third party, such as an offender, the National Health Insurance Corporation (hereinafter “Corporation or Defendant”) is exempted from the obligation to pay insurance benefits to the extent of the amount of compensation (Article 58(2) of the National Health Insurance Act). In such cases, the scope of expenses that the Service is exempt from the obligation to pay insurance benefits is limited to the amount that is equivalent to the ratio of perpetrator’s liability among the amount that arises from the perpetrator’s act, i.e., the amount that arises from the cause of the perpetrator’s act. Therefore, if a third party’s beneficiary received insurance benefits after compensation for damages, the Service is limited to the amount that the Service is entitled to collect as unjust enrichment from the beneficiary pursuant to Article 57 of the National Health Insurance Act (see Supreme Court en banc Decision 2018Da28793

B. According to the reasoning of the lower judgment, the following facts are revealed. On November 22, 2016, the Nonparty was subject to the instant accident, putting the freight truck on the crosswalk at the crosswalk. On December 8, 2016, the Plaintiffs, the parents of the Nonparty, agreed with the insurer of the said truck on behalf of the non-party who is a minor, and received an agreed amount of KRW 14 million including the future treatment cost, on behalf of the non-party on behalf of the non-party, who was paid KRW 8 million. After the agreement, the non-party was provided medical treatment to which the health insurance was applied to the injury caused by the instant accident, and in relation thereto, the Defendant was liable for KRW 3,677,90.

The lower court determined that the instant disposition was lawful on the ground that the scope of the Defendant’s collection of unjust enrichment pursuant to Article 57 of the National Health Insurance Act was the full amount of the Defendant’s expenses to be borne by the third party to the extent of the amount of damages paid by the third party to the beneficiary of insurance benefits. Accordingly, the Defendant’s payment notice to Plaintiff 1 of the instant disposition did not exceed eight million won for future medical treatment expenses paid by the Defendant in relation to the insurance benefits item.

C. However, according to the above legal doctrine, the scope of the Defendant’s collection of the charges by unjust enrichment is limited to the portion equivalent to the ratio of the perpetrator’s fault, not to the entire amount of KRW 3,677,90 borne by the Defendant. The lower court determined otherwise by misapprehending the legal doctrine on Article 58(2) of the National Health Insurance Act, thereby adversely affecting the conclusion of the judgment. The Plaintiff 1’s ground of appeal assigning this error is with merit.

3. Conclusion

The appeal by Plaintiff 1 is with merit, and this part of the judgment below against Plaintiff 1 is reversed, and that part of the case is remanded to the court below for further proceedings consistent with this Opinion. The appeal by Plaintiff 2 is dismissed as it is without merit, and the costs of appeal between Plaintiff 2 and the Defendant are assessed against the said Plaintiff. It is so decided as per Disposition by the assent of all participating Justices on the bench.

Justices Lee Dong-won (Presiding Justice)