Where a medical care institution prescribed by the National Health Insurance Act prepares by negligence a medical care institution's demand for medical care expenses erroneously stating medical care eligible for medical care benefits in the National Health Insurance Act, the standard for determining whether a proximate causal relationship exists between the medical care institution's breach of duty

Article 750 of the Civil Act

[Plaintiff-Appellant] Plaintiff 2005Da21821 decided Jul. 13, 2007 (Gong2007Ha, 1257)

Samsung Fire and Marine Insurance Co., Ltd. (Law Firm Subdivision, Attorneys Kim Young-soo et al., Counsel for the plaintiff-appellant)

Defendant (Attorney Song-soo et al., Counsel for the defendant-appellant)

Seoul Central District Court Decision 2014Na52673 Decided July 1, 2016

The part of the judgment below against the defendant is reversed, and the case is remanded to the Seoul Central District Court.

The grounds of appeal are examined.

1. Even if a medical care institution under the National Health Insurance Act prepares by negligence a medical care institution’s demand for medical care costs erroneously stating medical care items subject to health care benefits in the National Health Insurance Act, it cannot be deemed that the content of the demand for medical care costs should always be liable for damages against a third party who has transacted with the content of the demand for medical care costs. In order to recognize liability for damages, a proximate causal relation exists between a medical care institution’s breach of duty of care and a third party’s loss. Furthermore, determination of proximate causal relation should take into account not only the probability of occurrence of a result, the purpose and legal interest of the statute and other action regulations imposing the duty of care, the form of harmful act, the nature of the benefit from infringement, the degree of damage, etc. (see Supreme Court Decision 2005Da21

2. The lower court determined that, inasmuch as the Defendant, while operating a medical care institution prescribed in the National Health Insurance Act, provided medical treatment eligible for medical care benefits under the National Health Insurance Act, and received medical expenses exceeding the patient principal charges from the insured in the instant case, and accordingly, the Plaintiff additionally paid the insurance money corresponding to the difference between the non-benefit amount and the patient burden to the insured, the damage equivalent to the additionally paid insurance money that the Plaintiff paid was recognized as losses in proximate causal relation with the Defendant’s tort.

3. However, according to the reasoning of the judgment below, the Defendant issued to the insured of this case a written claim for medical expenses stating that medical expenses eligible for medical care fall under non-benefit items and received the payment of the medical expenses. This constitutes a case where the insured of this case violated the medical treatment contract and the obligations under the National Health Insurance Act and subordinate statutes related to the National Health Insurance Act. However, the Defendant merely entered into a medical contract with the insured, and cannot be deemed as bearing any obligation under the medical treatment contract with the Plaintiff who entered into an insurance contract with the insured, or violating the said obligation. Furthermore, it is difficult to view that the provision that prohibits the medical care benefit institution from claiming medical expenses equivalent to medical care benefits from the patient or his/her guardian is a provision

Examining these circumstances in light of the legal principles as seen earlier, even if the Defendant erred in failing to perform his/her duty of care while claiming medical expenses for the insured, there is no proximate causal relation between the error and the Plaintiff’s damage. Nevertheless, the lower court erred by misapprehending the legal principles on proximate causal relation between the Defendant’s tort and the Plaintiff’s damage, thereby adversely affecting the conclusion of the judgment.

4. Therefore, without examining the remaining grounds of appeal, the part against the defendant among the judgment below is reversed, and 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 Lee Ki-taik (Presiding Justice)