[1] In order to deem that there has been an agreement on medical fee insurance between the insurance company and the medical institution in accordance with Article 19(3) of the former Guarantee of Automobile Accident Compensation Act, whether a medical institution needs to be notified of the intention to pay medical fee and the limit of payment by the insurance company, etc. (affirmative)

[2] 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 with respect to the claim for medical fees covered by a medical institution, whether it is possible to claim the return of money paid to the medical institution (negative in principle), and whether the same applies to the case where it is proved that it is about king evidence not falling under the scope of recognition

[1] In light of the contents and purport of Articles 12(1) and (2), 19(1), and 19(3) of the former Guarantee of Automobile Accident Compensation Act (amended by Act No. 11690, Mar. 23, 2013; hereinafter “The Automobile Accident Compensation Act”), medical institutions need to be notified of the intention to pay medical fees and the limit of the payment of medical fees under automobile accident insurance in accordance with Article 12(1) of the Automobile Accident Compensation Act in order to deem that there exists an agreement on medical fees between an insurance company, etc. and a medical institution under Article 19(3) of the Automobile Accident Compensation Act.

[2] Article 12(1) of the former Guarantee of Automobile Accident Compensation Act (amended by Act No. 11690, Mar. 23, 2013; hereinafter “The Automobile Accident Compensation Act”) provides that an insurance company, etc. which received a notice of intent to pay medical fees covered by automobile insurance and the limit of payment pursuant to Article 12(2) of the Automobile Loss Compensation Act shall be deemed to have agreed to the contents of the medical institution’s claim if the insurance company did not request an examination to the Council on the Settlement of Medical Fees within 60 days from that time. Thus, the insurance company cannot seek a return of money paid to a medical institution without filing a request for examination of medical fees by a medical institution for medical fee claim, barring any special circumstance, for the reason that the claim for payment is unfairly applied to the medical fee, and even if it became clear that it does not fall under the scope of recognition of medical fees covered by automobile accident insurance.

[1] Articles 12(1) and (2), and 19(1) and (3) of the former Guarantee of Automobile Accident Compensation Act (Amended by Act No. 11690, Mar. 23, 2013) / [2] Articles 12(1) and (2), and 19(1) and (3) of the former Guarantee of Automobile Accident Compensation Act (Amended by Act No. 11690, Mar. 23, 2013); Article 741 of the Civil Act

Federation of Korea Passenger Transport Business Association

Medical Corporation, Sung Sejong Medical Foundation and one other (Law Firm ice, Attorneys Choi Young-sik et al., Counsel for the defendant-appellant)

Seoul Central District Court Decision 2012Na10859 Decided August 31, 2012

The part of the judgment below against the Defendants is reversed, and that part of the case is remanded to the Panel Division of the Seoul Central District Court.

The grounds of appeal are examined.

1. Article 12(1) of the former Guarantee of Automobile Accident Compensation Act (amended by Act No. 11690, Mar. 23, 2013; hereinafter “The Automobile Accident Compensation Act”) provides that “Where an insurance policyholder, etc., or a victim under the latter part of Article 10(1), or a traffic accident patient becomes aware of the occurrence of a traffic accident due to any other cause, the insurance company, etc. shall, without delay, notify the medical institution that provides the relevant traffic accident patient of its intention to pay medical fees and the limit of the payment thereof.” Paragraph (2) of the same Article provides that “A medical institution in receipt of notification from an insurance company, etc. of the intention to pay medical fees and the limit of the payment thereof from the insurance company, etc. pursuant to Article 15 may file a claim for automobile accident insurance with the relevant insurance company, etc. according to the standards publicly notified by the Minister of Land, Transport and Maritime Affairs pursuant to Article 12(1) shall be deemed to have unfairly applied the standards for claiming medical fees pursuant to Article 12(2).”

In light of the contents and purport of the above provisions, in order to consider that there has been an agreement between the insurance company and the medical institution on medical fees covered by automobile insurance pursuant to Article 19(3) of the Automobile Loss Act, it is necessary for the medical institution to receive the notification of the intention to pay the medical fees covered by automobile insurance and the limit of the payment thereof from the insurance company, etc. pursuant to Article 12(1)

In addition, since an insurance company, etc. which received the payment of medical fee from the medical institution that received the above notification pursuant to Article 12 (2) of the Automobile Loss Compensation Act, if it did not request review within 60 days from the time when the committee for the dispute resolution of medical fee insurance claims filed a claim for medical fee payment by the medical institution, the insurance company cannot claim the return of the amount paid to the medical institution on the ground that the claim for payment of medical fee was made unfairly applying the standard of medical fee covered by automobile insurance unless there are special circumstances. The same applies to the case where it was revealed that the claim for payment was made based on the king evidence that does not fall under the scope of the

2. Based on the evidence adopted, the lower court determined that the agreement was not concluded on the ground that there was no evidence to prove that the Plaintiff was informed of Article 12(1) of the Automobile Loss Compensation Act regarding the traffic accident of this case to the Defendant hospital, on the ground that the Plaintiff and the Defendant hospital did not have reached an agreement between the Plaintiff and the Defendant hospital on the ground that the Plaintiff did not recognize that there was no evidence to prove that the Plaintiff gave notice under Article 12(3) of the Automobile Loss Compensation Act to the Defendant hospital regarding the traffic accident of this case.

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

A. In a case where a party asserts a certain legal effect and fails to close the elements and omitted part of the elements, the court shall point out the omitted facts, clarify what the party did not present this point, and provide the party with an opportunity to present his/her argument. In a case where it is evident that the party did not prove due to negligence or misunderstanding or where there is no explicit dispute between the parties as to the matter to be at issue, the court shall question the party and urge him/her to present his/her opinion. If the court intends to determine the propriety of the claim on the grounds of the legal point of view that the party did not know at all or could not have anticipated, it shall give the party an opportunity to state his/her opinion regarding the legal point of view, and if the court intends to decide the propriety of the claim on the grounds of the legal point of view that the party did not know at all or could not have anticipated, it commits an unlawful act that did not properly examine the party by failing to perform his/her duty of explanation (see, e.g., Supreme Court Decisions 2002Da6027, Mar. 111, 2009).

B. According to the reasoning of the judgment below, the defendant hospital claimed KRW 10,936,750 as medical fee after treating Codefendant 1 of the first instance court, who is a traffic accident patient, and the plaintiff claimed KRW 10,070,450 among them. If the plaintiff, who is an automobile insurance company, paid medical fee in response to the claim of the defendant hospital that treated the traffic accident patient, then the procedure for notification, etc. under Article 12(1) of the Automobile Loss Act had already been completed in any way. According to the records, the plaintiff and the defendants, who are the victim of the traffic accident, were only disputed about whether the disease of Codefendant 1 of the first instance court, who is the victim of the traffic accident, constitutes king, or whether the defendants performed an operation without recognizing that the disease falls under king, and there was no dispute about the part of notification under Article 19(3) of the Automobile Loss Act, which is the requirement for the application of Article 12(1).

Nevertheless, the lower court determined that the Plaintiff did not reach an agreement pursuant to Article 19(3) of the Automobile Loss Act on the ground that the Plaintiff did not notify the Defendant Hospital of Article 12(1) of the said Act, which led to the failure of the agreement. This is a justifiable ground for appeal by the Defendants, which points out this out, on the ground of the legal point of view that the Defendants could not have anticipated at all, to determine the propriety of the claim on the ground of the legal point of view. In so doing, the lower court erred by failing to properly examine in violation of the duty of explanation, thereby adversely affecting

4. Therefore, without examining the remaining grounds of appeal, the part of the judgment below against the Defendants 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.

Justices Ko Young-han (Presiding Justice)