[1] The scope of damage claim that the National Health Insurance Corporation obtains by subrogation of a victim of a tort under Article 58 (1) of the National Health Insurance Act, and the meaning of "damage claim for the same reason as the health insurance benefit" here

[2] In a case where the National Health Insurance Corporation provided health insurance benefits to the victim of a tort, whether the damage claim equivalent to the medical expenses eligible for non-payment can be obtained in subrogation of the victim (negative)

[1] Article 58(1) of the National Health Insurance Act / [2] Article 58(1) of the National Health Insurance Act, Article 41 of the former National Health Insurance Act (Amended by Act No. 13985, Feb. 3, 2016); Article 9(1) [Attachment 2] of the former Regulations on the Standards for Medical Care Benefits in National Health Insurance (Amended by Ordinance of the Ministry of Health and Welfare No. 431, Aug. 4, 2016)

[1] Supreme Court Decision 2014Da206853 Decided September 10, 2015 (Gong2015Ha, 1488)

National Health Insurance Corporation

Defendant 1 and one other (Law Firm Sejong Chang, et al., Counsel for the defendant-appellant)

Suwon District Court Decision 2016Na62874 decided May 12, 2017

Of the judgment of the court below against Defendant 1 and the part against Defendant interesting fire and marine insurance companies, the part ordering payment in excess of KRW 2,299,295 shall be reversed, and this part of the case shall be remanded to the Panel Division of the District Court.

The grounds of appeal are examined.

1. Basic factual basis

The court below acknowledged the following facts.

A. Defendant 1: (a) worked in the first instance court’s joint Defendant’s golf course operated by the ○○○○○○○○○ Group, which is affiliated with the Republic of Korea; (b) concluded a liability insurance contract for sports facility operators with respect to the Defendant interesting State Fire and Marine Insurance Co., Ltd. (hereinafter “Defendant interesting State Fire”) and the △△ Golf course.

B. On October 17, 2014, Defendant 1: (a) an accident that was crashed by the Nonparty, who was on the back-site during which he operated the electric cart within the said golf course; and (b) the Nonparty died on October 18, 2014 due to the light blood transfusion, etc. (hereinafter “instant accident”).

C. 1,414,61 won for the medical expenses of the Nonparty due to the instant accident (i.e., the Plaintiff’s medical care benefit cost of KRW 7,402,110 for the Corporation + KRW 595,540 for the Nonparty’s personal charge + KRW 3,417,01 for the Nonparty’s non-benefit treatment cost).

2. The judgment of the court below

Based on the above facts, etc., the lower court determined that Defendant 1 was liable for damages equivalent to the medical expenses that the Plaintiff may exercise on behalf of the Nonparty, 3,424,398 won (=1,414,661 won x 0.3), and that the actual expenses paid to medical care institutions are more than KRW 7,402,110, and thus, Defendant 1 was liable to pay the Plaintiff the damages amounting to KRW 3,424,398 and the damages for delay thereof, jointly and severally with Defendant 1, and jointly with Defendant 3,324,398, and damages for delay.

The above determination by the court below was based on the interpretation of the above legal provision that the scope of damage claim equivalent to the medical expenses of the victim in subrogation of the plaintiff on the ground of the legislative purport and text of Article 58 (1) of the National Health Insurance Act intending to resolve the problem of double benefit of the victim and to promote the financial soundness of the national health insurance, including all medical expenses in proximate causal relation with the accident of this case.

3. As to the Defendants’ common grounds of appeal

A. If a victim of a tort provided health insurance benefit under the National Health Insurance Act (hereinafter “health insurance”), the National Health Insurance Corporation shall obtain the victim’s damage claim against the perpetrator within the limit of the expenses incurred in providing such insurance benefit (Article 58(1) of the National Health Insurance Act). This is to prevent the victim who received the health insurance benefit from obtaining double benefit by receiving damages from the perpetrator again. As such, the damage claim that the National Health Insurance Corporation received by subrogation of the victim is limited to the damage claim for the same reason as the health insurance benefit out of the total health insurance benefit of the victim (see Supreme Court Decision 2014Da206853, Sept. 10, 2015). Here, the damage claim for the same reason as the health insurance benefit refers to the case where the damage claim for the perpetrator can be extinguished by compensating for the damage claim for the same reason as the health insurance benefit as the health insurance benefit

Meanwhile, Article 41(1) of the former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter “former Health Insurance Act”) provides that “the provision of medical care benefits falling under each of the following subparagraphs shall be provided to the insured and their dependents with respect to their diseases, injuries, childbirth, etc.” (Article 41(1)). Under each of the above provision, “the methods, procedures, scope, and limits of medical care benefits under paragraph (1) shall be prescribed by Ordinance of the Ministry of Health and Welfare” (Article 41(3) of the former Health Insurance Act provides that “The Minister of Health and Welfare may exclude the scope of duties or daily lives when determining the criteria for medical care benefits under paragraph (2) and other matters prescribed by Ordinance of the Ministry of Health and Welfare may be excluded from those subject to medical care benefits,” and Article 41(1) of the former Rules on Medical Care Benefits (amended by Ordinance of the Ministry of Health and Welfare No. 1841, Apr. 1, 2016).

According to this, the subjects of health insurance benefits provided by the National Health Insurance Corporation and those of non-health insurance benefits are distinguished from each other, and thus, the claim for damages equivalent to the treatment costs of non-benefit is not extinguished due to the provision of insurance benefits for those eligible for health insurance benefits. Therefore, the two cannot be deemed as a complementary relationship. Therefore, since the damage claim equivalent to the treatment costs of non-benefit out of the total damage claim of the victim cannot be deemed as the damage claim equivalent to the health insurance benefits for the same reason, the National Health Insurance Corporation that provided the health insurance benefits cannot obtain the damage claim equivalent to the treatment costs of non-benefit in subrogation of the victim.

B. Therefore, the claim for damages equivalent to KRW 3,417,01 of the non-party’s damage claim cannot be deemed as the damage claim for the same reason as that of the Plaintiff’s insurance benefit. Therefore, the Plaintiff may not exercise the damage claim equivalent to the above non-party’s damage claim in subrogation of the non-party.

Nevertheless, the lower court’s determination that the Plaintiff may subrogate the damage claim equivalent to the above non-benefit treatment costs is erroneous by misapprehending the legal doctrine regarding the scope of the Plaintiff’s subrogation right who provided insurance benefits under the National Health Insurance Act, thereby adversely affecting the conclusion of the judgment. The allegation contained in the grounds

4. As to Defendant 1’s grounds of appeal

For the reasons indicated in its reasoning, the lower court determined that Defendant 1 caused the instant accident by neglecting his duty of care as a full-time driver.

In light of the relevant legal principles and records, the above determination by the court below is just, and contrary to what is alleged in the grounds of appeal, there were no errors by misapprehending the legal principles regarding a driver’s duty of care and causation, or by exceeding the bounds of the principle

5. Conclusion

Therefore, among the judgment below against Defendant 1 and the part against Defendant interesting fire, the part ordering payment in excess of KRW 2,299,295 among the part against which Defendant interesting fire was lost is reversed, and this 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 Ahn Jae-chul (Presiding Justice)