Plaintiff (Law Firm Cheong, Attorneys malewon et al., Counsel for the plaintiff-appellant)

National Health Insurance Corporation (Attorney Cho Jae-ho, Counsel for defendant-appellant)

November 26, 2015

1. The plaintiff's claim is dismissed.

2. The costs of lawsuit shall be borne by the Plaintiff.

The defendant shall pay to the plaintiff 91,749,243 won with 5% interest per annum from the day following the day when he received the complaint of this case to the day when he received the application for modification of the purport of the claim of this case and the cause of the claim of this case, 15% interest per annum from the next day to the day of complete payment

1. Basic facts

The following facts may be acknowledged if there is no dispute between the parties, or if the purport of the whole pleadings is added to each entry in Gap evidence 1 to 4 (including the serial number).

A. Status of the parties

The plaintiff is the non-party 1's dependent who is the health insurance policyholder under the National Health Insurance Act, and the defendant is a non-profit public interest corporation that manages and operates health insurance affairs concerning the prevention, diagnosis, medical treatment, and rehabilitation of the people's diseases and injuries, childbirth, death, health promotion, etc.

(b) Occurrence of an accident;

On June 10, 2008, the Plaintiff participated in the ○○, Middle and High School 005, and went to the front side of the Gyeonggi Pyeong-gun, the Plaintiff was injured by the accident that goes to the right side in the course of driving along two lanes among the 2-lane roads located in the purchase tunnel located in the Namyang-si, Namyang-si, Namyang-si, and caused the injury of the Plaintiff, such as the alley-1st century and the complete horse, etc.

(c) Payment of insurance money;

(1) At the time of the instant accident, Non-party 2, the supervisor of the inter-facel department, operated the instant vehicle (vehicle registration number omitted) car (hereinafter “instant vehicle”). However, Hyundai Marine Fire Insurance Co., Ltd., the insurer of the instant vehicle (hereinafter “former Marine Fire”) rejected the Plaintiff’s guarantee of payment for the medical expenses by asserting that the instant accident was not a traffic accident but an accident occurred in the course of the Plaintiff’s getting on and off the inter-facel, and the Defendant paid the medical care benefits under the National Health Insurance Act and the Plaintiff directly to the hospital.

B. On August 18, 2008, at the police investigation, Nonparty 2 stated that the accident of this case was caused by Nonparty 2’s shocking the Plaintiff as the instant vehicle, and upon receiving the traffic accident regarding the instant accident in Hyundai Marine Fire, Hyundai Marine Fire guaranteed the payment of medical expenses to the hospital hospitalized by the Plaintiff, and accordingly, the Defendant suspended the payment of medical expenses to the Plaintiff. On October 13, 2008, Hyundai Marine Fire paid KRW 12,739,620 to the Plaintiff prior to the payment guarantee, and recovered KRW 14,414,50 to the Defendant on May 18, 2009, after paying KRW 26,440 to the Plaintiff.

D. The plaintiff and Hyundai Marine Fire Damage Action

On December 28, 2009, the Plaintiff filed a lawsuit against Hyundai Marine Fire as Seoul Central District Court 2009Da488314, but the judgment dismissing the Plaintiff’s claim on February 18, 2011 on the ground that there was no evidence to prove that the instant vehicle caused the instant accident due to the shock of the Plaintiff. The judgment dismissing the Plaintiff’s appeal was rendered on November 8, 2012 in the Seoul Central District Court 201Na18269, which is the appellate court, and the judgment dismissing the appeal was rendered on November 8, 2012, and the Plaintiff appealed to the Supreme Court 2013Da2313, but the Plaintiff appealed to the Supreme Court 2013Da2313, on April 11, 2013.

E. Lawsuit claiming return of unjust enrichment against the plaintiff of modern marine fire

Hyundai Marine Fire was sentenced to dismissal of the Plaintiff’s claim in Seoul Central District Court case No. 2009Gadan488314, Sept. 26, 201, and filed an application with the Seoul Central District Court for a payment order against the Plaintiff for the return of medical expenses, etc. paid to the hospital, but, upon the Plaintiff’s objection, the lawsuit was brought to return unjust enrichment at the same court 201Gahap120311, and the said court rendered a judgment on August 20, 2014 that “the Plaintiff shall pay to Hyundai Marine Fire KRW 115,849,130, and delay damages therefrom. The Plaintiff paid the principal amount to Hyundai Marine Fire KRW 115,849,130 and KRW 12,917,971, KRW 128,767,101, KRW 767,101.

(f) Lawsuits between the Plaintiff and Gyeonggi-do School Safety Mutual Aid Association

(1) Meanwhile, the Plaintiff filed a lawsuit against the Gyeonggi-do School Safety Mutual Aid Association for the payment of mutual aid money under the Act on the Prevention of and Compensation for School Safety Accidents (hereinafter “School Safety Accident Compensation Act”) with the Jung-do District Court 201Kahap2989, and the said court rendered a judgment ordering the Plaintiff to pay KRW 126,691,210 to the Plaintiff on August 26, 2011.

In the case of the Seoul High Court 201Na79403, the appellate court entrusted the fact-finding inquiry that the plaintiff's medical expenses are different from the insurer's charges, personal charges, non-insurance, etc. However, the current national health insurance calculation system and the automobile insurance submission system were different from the criteria to calculate the amount of the plaintiff's medical expenses.

Article 41 of the National Health Insurance Act provides that the medical care benefits to be borne by the Gyeonggi-do School Safety Mutual Aid Association shall be the amount borne by the beneficiary or his/her guardian pursuant to the provision of Article 41 of the National Health Insurance Act among the expenses incurred in treating the injury or disease suffered by the beneficiary. The 15,849,130 won returned by the Plaintiff to Hyundai Marine and Fire is the medical expenses computed in accordance with the provisions of the Guarantee of Automobile Compensation Act on the premise that the instant accident is traffic accident. The standards for calculating medical care fees under the Guarantee of Automobile Compensation Act and the medical care benefits under the National Health Insurance Act are different. The 4,833,610 won, excluding the 4,83,610 won, cannot be distinguished from the medical care benefits to be borne by the Defendant and the damages incurred by the Plaintiff on February 20, 2014. The judgment of the appellate court became final and conclusive on June 12, 2014.

2. The assertion and judgment

A. The plaintiff's assertion

The instant accident is not a traffic accident but a school safety accident caused by the Plaintiff to be in excess of the course of training with the inter-school team, and thus, the Defendant is obligated to return it as unjust enrichment to the Plaintiff, since the Defendant was the Seoul Central District Court Decision 2011Gahap120311, 10 won, excluding the principal charges, out of the total amount of KRW 115,849,130, which was paid by the Plaintiff to Hyundai Maritime Fire according to the judgment of the lawsuit claiming return of unjust enrichment.

(b) the relevant regulations;

former National Health Insurance Act (amended by Act No. 9386 of January 30, 2009)

Article 39 (Medical Care Benefits)

(1) The following medical care benefits shall be provided for the disease, injury, childbirth, etc. of policyholders and their dependents:

1. Diagnosis and examination;

2. Provision of medicine and materials for medical treatment;

3. Treatment, operation and other medical care;

4. Prevention and rehabilitation;

5. Hospitalization;

6. Nursing;

7. Transfer.

Article 40 (Medical Care Institutions)

(1) Medical care benefits (excluding nursing and delivery) shall be provided by the following medical care institutions. In this case, the Minister for Health, Welfare and Family Affairs may exclude the medical institutions, etc. as prescribed by the Presidential Decree, which are deemed unfit for medical care institutions for the public interest or national policy,

1. Medical institutions established under the Medical Service Act;

2. Pharmaciess registered under the Pharmaceutical Affairs Act;

3. The Korea Orphan Drug Center established pursuant to Article 72-12 of the Pharmaceutical Affairs Act;

4. Public health centers, public health centers and their branches under the Regional Public Health Act;

5. Public health clinics established pursuant to the Act on Special Measures for Public Health and Medical Services in Agricultural and Fishing Villages;

(2) The Minister for Health, Welfare and Family Affairs may recognize the medical care institutions that meet the standards prescribed by Ordinance of the Ministry for Health, Welfare and Family Affairs as specialized general medical care institutions or specialized medical care institutions, such as facilities, equipment, human resources, and specialized medical care areas,

(4) Medical care institutions referred to in paragraphs (1) and (2) shall not refuse to provide medical care benefits without any justifiable reason.

Article 41 (Partial Defrayment of Expenses)

A person who receives medical care benefits referred to in the provisions of Article 39 (1) shall personally bear part of such expenses (hereinafter referred to as “co-payment”) under the conditions as prescribed by the Presidential Decree.

Article 42 (Calculation, etc. of Medical Care Benefit Costs)

(1) Medical care benefit costs shall be determined by a contract between the president of the Corporation and persons representing the medical and pharmaceutical communities determined by the Presidential Decree.

(2) Where a contract has been concluded pursuant to the provisions of paragraph (1), it shall be deemed to have been concluded between the Corporation and each individual medical care institution.

(3) The contract under paragraph (1) shall be concluded not later than 75 days prior to the expiration date of contract period, and if the contract is not concluded by such deadline, the amount determined by the Minister of Health and Welfare through a resolution of the Deliberation Committee shall be the medical care benefit cost. In this case, the medical care benefit cost determined by the Minister of Health and Welfare shall be

(4) Where the medical care benefit costs are determined under the provisions of paragraph (1) or (3), the Minister for Health, Welfare and Family Affairs shall notify without delay the details of the medical care benefit costs.

(5) The president of the Corporation shall, in concluding a contract under paragraph (1), undergo a deliberation and resolution by the finance operation committee under Article 31.

(6) Where the president of the Corporation requests materials necessary to conclude a contract under paragraph (1), the Health Insurance Review and Assessment Service under Article 55 shall faithfully comply therewith.

Article 43 (Claims for and Payment of Medical Care Benefit Costs)

(1) Medical care institutions may claim the Corporation to pay medical care benefit costs. In this case, the request for examination referred to in the provisions of paragraph (2) shall be deemed the claim for medical care benefit costs for the

(2) Medical care institutions which intend to claim medical care benefit costs under paragraph (1) shall file a request for review of medical care benefit costs with the Health Insurance Review and Assessment Service under Article 55, and the Health Insurance Review and Assessment Service in receipt of such request for review shall, after examining the request, notify without delay the Corporation

(3) The Corporation notified of the contents of examination under the provisions of paragraph (2) shall pay without delay medical care benefit costs to the medical care institutions according to the contents. In this case, if the amount of co-payment already paid exceeds the amount notified under the provisions of paragraph (2), the insured shall be paid by deducting the excessive amount paid to the medical care institutions.

(4) The Corporation may, for accounting, offset the amount to be paid to a policyholder under the provisions of paragraph (3) against the insurance premiums and other collections under this Act which the relevant policyholder should pay (hereinafter referred to as "insurance premiums, etc.").

(5) Where the Health Insurance Review and Assessment Service under paragraph (2) evaluates and notifies the appropriateness of health care benefit under Article 56 in paying health care benefit costs, the Corporation shall pay it by adding or reducing the health care benefit costs according to the results of relevant assessment. In such cases, the criteria for calculating the increase or decrease of health care benefit costs by the results of assessment shall

C. Determination

According to the relevant regulations, medical care benefits under the Medical Insurance Act shall, in principle, be considered to be in the form of spot benefit for medical care until the disease or injury is cured by the medical care dealing agency designated by the insurer or the insurer’s organization (Supreme Court Decision 94Da46046 delivered on December 9, 1994), and each medical care institution which has provided benefits requests the re-determination of medical care benefits for the heart members, and the defendant is obliged to pay the expenses according to the result of the examination by evaluating the appropriateness of the medical care benefits and by evaluating the appropriateness of the medical care benefits from the heart members,

According to the evidence evidence Nos. 7 through 11, the head of the △△ University, the head of the △△ University, the head of the Dodong Rehabilitation Center, the head of the Gudong Culture Hospital, the head of △△△△△△△△△△△△△△△△△△△△△△△△△△△, and the head of the relevant medical institution divided the Plaintiff’s personal charges and the Defendant’s medical care benefits charges into KRW 91,749,243, among the total medical expenses in the relevant medical institution. However, the above medical expenses are medical expenses calculated by motor vehicle insurance fees under the Guarantee of Automobile Compensation Act, which cannot be deemed as medical care benefits under different National Health Insurance Act, and cannot be determined as having been exempted from payment of the above amount. In light of the fact that the Plaintiff only has the right to claim for medical care expenses under the National Health Insurance Act, and that the Plaintiff could have selected whether to receive medical care benefits or whether to receive insurance benefits in accordance with the insurance company’s compensation standards, and thus, the Plaintiff’s claim for medical expenses cannot be justified.

3. Conclusion

The plaintiff's claim is dismissed.

Judges Ori-hee