[1] The meaning of "a case arising from a criminal act committed by intention or gross negligence" under Article 48 (1) 1 of the former National Health Insurance Act

[2] The case holding that the circumstance to the extent that the other party caused the other party's failure to conduct an examination for the purpose of defending it does not constitute a ground for restricting insurance benefits under Article 48 (1) 1 of the former National Health Insurance Act

[1] Article 48 (1) 1 of the former National Health Insurance Act (amended by Act No. 9022 of Mar. 28, 2008) provides that insurance benefits shall be limited in cases where a criminal act is committed intentionally or by gross negligence, or an insurance accident is caused intentionally. However, as specified in Article 1, it is strictly interpreted that the requirements for the restriction on benefits under the above provision should be strictly interpreted to improve public health and promote social security by providing insurance benefits for the prevention, diagnosis, treatment, rehabilitation, childbirth, death, and improvement of health of the citizens as specified in Article 1.

[2] The case holding that the circumstance to the extent that the other party caused the other party to defend himself does not constitute a ground for restricting insurance benefits under Article 48 (1) 1 of the former National Health Insurance Act (amended by Act No. 9022 of March 28, 2008)

[1] Article 48 (1) 1 of the former National Health Insurance Act (amended by Act No. 9022 of March 28, 2008) / [2] Article 48 (1) 1 of the former National Health Insurance Act (amended by Act No. 9022 of March 28, 2008)

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

Plaintiff (Attorney Park Byung-hoon, Counsel for the plaintiff-appellant)

National Health Insurance Corporation

July 2, 2008

1. The Defendant’s disposition of restitution of KRW 2,713,230 against the Plaintiff on July 2, 2007 is revoked.

2. The costs of the lawsuit are assessed against the defendant.

The same shall apply to the order.

1. Details of the instant disposition

A. On June 4, 2006, at around 01:20, the Plaintiff was suffering from injury, such as an injury on the left-hand side and a mouth, etc. (hereinafter “the injury in this case”), which requires 8 weeks’ treatment by collectively assaulting from Nonparty 2, 3, and 4, who was fluencing Nonparty 1 and flucing Nonparty 1 to walk with Nonparty 1. In addition, the Plaintiff suffered from the injury to the left-hand side in need of 8 weeks’ treatment by collectively assaulting Nonparty 2, 3, and 4.

B. As a result, the Plaintiff received treatment at the Incheon National University Offset Bag Hospital and the National Institute of Home Medical Service. Of the medical expenses incurred in the course of the treatment, the Defendant paid KRW 2,713,230 to the Defendant as the insurance benefit cost.

C. However, the Defendant, on July 2, 2007, determined the above insurance benefit costs of KRW 2,713,230 as unjust enrichment and notified the Plaintiff of the payment thereof (hereinafter “instant disposition”) on the ground that the Plaintiff’s instant injury was incurred in the course of exercising mutual violence, not unilaterally from the other party, but by exercising mutual violence, which constitutes “when a criminal act is committed by intention or gross negligence or intentionally causes an accident” as provided by the National Health Insurance Act under the National Health Insurance Act.

[Reasons for Recognition] Facts without dispute, Gap evidence 1, Gap evidence 2, Gap evidence 5-1 through 4, Gap evidence 11 through Gap evidence 13, Eul evidence 2, and the purport of the whole pleadings

2. Whether the instant disposition is lawful

A. The plaintiff's assertion

The Plaintiff merely suffered the instant injury by unilaterally committing an assault from Nonparty 1’s perpetrator, and the Plaintiff was charged with a violation of the Punishment of Violences, etc. Act in relation to the instant case and was subject to suspension of indictment. However, this merely leads to the Plaintiff’s physical ties for defense in a situation where the Plaintiff unilaterally committed an assault, and thus, cannot be deemed as constituting “criminal act due to intention or gross negligence” under the National Health Insurance Act, and the Defendant’s disposition with a different purport is unlawful.

B. Relevant statutes

former National Health Insurance Act (amended by Act No. 9022, Mar. 28, 2008; hereinafter “Act”)

Article 1 (Purpose)

The purpose of this Act is to improve national health and promote social security by providing citizens with insurance benefits for the prevention, diagnosis, medical treatment, and rehabilitation of diseases and injury, childbirth, death, and improvement of health.

Article 48 (Restriction on Benefits)

(1) When a person who is eligible to receive insurance benefits falls under any of the following subparagraphs, the NHIS shall not provide any insurance benefit:

1. When he has intentionally or through gross negligence caused a criminal act or intentionally contributed to the occurrence of an accident;

Article 52 (Collection of Unjust Enrichment)

(1) The NHIS shall collect all or part of the amount equivalent to the relevant benefits or expenses for benefits from a person who has received insurance benefits or a medical care institution that has received insurance benefit costs by deceit or other fraudulent means

Article 53 (Right to Indemnity)

(1) When the Service has provided a subscriber with the insurance benefits as a cause for the insurance benefits occurred due to the act of a third party, it shall obtain the right to claim compensation for such third party within the limit of the expenses required for such benefits.

(c) Markets:

(1) In light of Article 48(1)1 of the Act, the purpose of the Act is to prevent, diagnose, treat, and recover from the disease and injury of the citizen, to give birth and death, and to promote social security by providing insurance benefits to the citizens for the prevention, diagnosis, and rehabilitation of the disease and injury, as well as to promote their health, as stipulated in Article 1 of the Act, the requirements for the restriction on benefits under the above Act should be strictly interpreted (see, e.g., Supreme Court Decision 2002Du12175, Feb. 28, 2003), and Article 48(1)1 of the Act should be construed as "where a criminal act is caused by intention or gross negligence" as stipulated in Article 1 of the Act.

(2) However, considering the overall purport of pleadings as to Gap evidence 2 through Gap evidence 4, Gap evidence 9, Eul evidence 15-1 through 4, Eul evidence 15-1-2, and Eul evidence 1-2, the non-party 1 was punished for the reason that the plaintiff was about to her own, first of all, the plaintiff's eye and body body was her drinking, and the non-party 1's behavior was also her drinking, and the non-party 1 suffered the injury of the plaintiff. The non-party 1 was prosecuted for the crime of causing the injury of the plaintiff in collaboration with Eul and the non-party 1, and was sentenced to the non-party 1 to the non-party 2,80 hours of imprisonment with prison labor for 206Da2075 on December 13, 2006, the non-party 1 and the non-party 2 were investigated by the court of first instance on the ground that the plaintiff and the non-party 1 were 0-party 1's face and 2's face.

(3) According to the above facts, the injury of this case suffered by the plaintiff is caused by the act committed by the non-party 1, and the legislative purport of the National Health Insurance Act, the strict interpretation of the provision on payment restriction, and the purport of the provision on the right to indemnity under Article 53 (1) of the National Health Insurance Act, the circumstance of the occurrence of this case and the degree of harm to the non-party 1, etc., in light of the above facts, it cannot be deemed that the injury of this case constitutes a ground for restricting insurance benefits under Article 48 (1) 1 of the Act, and there is no other evidence to acknowledge it otherwise.

3. Conclusion

Therefore, the plaintiff's claim of this case is reasonable, and it is so decided as per Disposition by admitting it.

Judges Jeon Sung-soo (Presiding Judge)