Plaintiff (Attorney Im Chang-soo, Counsel for the plaintiff-appellant)

National Health Insurance Corporation

September 5, 2019

1. The plaintiff's claim is dismissed.

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

The defendant's disposition of restitution notice of KRW 50,924,280 against the plaintiff on May 2, 2017 shall be revoked.

1. Details of the disposition;

A. The Plaintiff is a national health insurance policyholder.

B. On September 18, 2016, at around 13:45, the Plaintiff driven a two-wheeled vehicle at the intersection of 1520 (hereinafter “instant intersection”) in accordance with the Young-gu, Young-si, Suwon-si, Suwon-si (hereinafter “instant intersection”), and proceeded along seven-lanes in the direction of the spode in the direction of the spode in the direction of the spode in the direction of the spode in the direction of the spode (hereinafter “instant traffic accident”).

C. The Plaintiff suffered injuries, such as the pelvis and the pelvise of the instant traffic accident, the pelvis, the pelvis of the pelvis, the pelvise, the pelvise of hand, and the lavise, and the laume of the ○○ Hospital, etc., to treat the said injuries.

D. On May 2, 2017, the Defendant rendered a disposition of restitution of unjust enrichment against KRW 50,924,280, which the Plaintiff received based on Articles 53(1) and 57 of the National Health Insurance Act, on the ground that “the instant traffic accident occurred due to gross negligence, i.e., the Plaintiff’s violation of the Plaintiff’s signal” (hereinafter “instant disposition”).

E. On July 20, 2017, the Plaintiff filed an objection against the instant disposition with the Defendant, and the Defendant’s objection committee dismissed the Plaintiff’s objection on September 22, 2017. Thereafter, the Plaintiff filed an administrative appeal against the instant disposition with the Health Insurance Dispute Mediation Committee, and the Health Insurance Dispute Mediation Committee dismissed the Plaintiff’s claim on February 18, 2019.

[Ground of recognition] Facts without dispute, Gap evidence Nos. 1 through 3, Eul evidence No. 1, the purport of the whole pleadings

2. Whether the instant disposition is lawful

A. The plaintiff's assertion

While the Plaintiff was driving along an intersection in violation of the signal at the time of the instant traffic accident, the instant traffic accident was caused by the Plaintiff’s negligence, not intentional or gross negligence, rather than by the Plaintiff’s “accident”; the instant traffic accident was caused by the Plaintiff’s failure to drive, stroke, temporary corrosion, etc.; and the Plaintiff was subject to a non-prosecution disposition (Suspension of Prosecution) on the charge of violating the Act on Special Cases Concerning the Settlement of Traffic Accidents (Bodily Injury) by taking into account the favorable circumstances for the Plaintiff into account, the mere fact that the Plaintiff caused the instant traffic accident in violation of the signal cannot be deemed to have committed an intentional or gross negligence against

B. Determination

1) Relevant legal principles

A) Article 53(1)1 of the National Health Insurance Act provides that insurance benefits shall be limited to “where a person has caused a criminal act by intention or gross negligence or intentionally caused an accident”. In light of the fact that the National Health Insurance Act aims to improve citizens’ health and promote social security by providing citizens with insurance benefits for the prevention, diagnosis, medical treatment, rehabilitation, childbirth, death, and improvement of health, as provided in Article 1, the National Health Insurance Act aims at the improvement of citizens’ health and the promotion of social security (see Supreme Court Decision 2002Du12175, Feb. 28, 2003). As such, “where a criminal act by intention or gross negligence has caused an accident” as provided in Article 53(1)1 of the same Act is construed as “where a criminal act by intention or gross negligence has occurred entirely or has caused a criminal act by intention or gross negligence” (see Supreme Court Decision 2010Do710, Jul. 10, 2010).

B) Meanwhile, the proviso of Article 3(2)1 and the proviso of Article 4(1)1 of the Act on Special Cases concerning the Settlement of Traffic Accidents provide that if a driver who commits a crime of bodily injury caused by occupational traffic in violation of signal apparatus and commits the crime, he/she may institute a public prosecution even if the victim does not want punishment or the vehicle which caused a traffic accident is subscribed to comprehensive vehicle insurance, etc. taking into account that the vehicle is essential circumstances in daily life, the above provision provides that a driver who commits a crime of bodily injury caused by occupational traffic in order to facilitate prompt recovery from traffic accident damage by inducing the driver to subscribe to agreements or comprehensive insurance with the victim, without instituting a public prosecution where the driver who commits a crime of bodily injury caused by occupational traffic in order to ensure prompt recovery from traffic accident damage. In light of the legislative intent of Article 53(1)1 of the National Health Insurance Act and Article 53(1)1 of the Act on Special Cases concerning the Settlement of Traffic Accidents, it shall not be deemed that the occurrence of an accident constitutes a traffic accident in violation of Article 3(1)1).

(ii) the facts of recognition

A) On September 18, 2016, the instant traffic accident occurred around 13:45, and the instant intersection was flat and the weather was clear and dried and there was no obstacle to securing the view.

B) At the time of the Plaintiff’s entry into the instant intersection, the signal of the proceeding direction was already red, and the number of vehicles with four, five, and six lanes were stopped in the signal signal atmosphere. The victim’s vehicle began to turn to the left and continued to turn to the left at least five lanes in the direction of the Plaintiff’s proceeding.

C) The victim is waiting at the left turn from the two lanes, and the left turn to the left turn from the scarde in accordance with the new subparagraph, the left turn was almost finished, and the instant traffic accident occurred immediately before the entry into the straight line with the direction of the amamsa.

라) 피해자는 수사기관에서 ‘신호 바뀌는 것을 보고 N 기어에서 D 드라이브로 바꾸고 사이드 브레이크를 내리고 출발했으니 신호 바뀌고 3~4초 정도 경과하여 출발하였다.’, ‘속도는 10~15km 정도였고, 상대 오토바이 속도는 충격 정도와 충격 후 차가 돌아가 있었던 것을 봤을 때 상당히 빨랐다고 생각한다.’고 진술하였다.

E) On the other hand, on November 24, 2016, the prosecutor of the Suwon District Prosecutors' Office issued a non-prosecution disposition of suspension of indictment against the Plaintiff on the ground that the Plaintiff’s suspicion of violation of the Plaintiff’s Act on Special Cases Concerning the Settlement of Traffic Accidents (the fact of suspicion is acknowledged, but compensation is possible for the victims up to KRW 30 million by mandatory insurance admitted to the motor bicycle operated by the Plaintiff, and the Plaintiff also suffered from serious injury caused by the instant traffic accident, etc.

[Ground of recognition] Facts without dispute, Gap evidence 4-1, 2-2, Eul evidence 5, the purport of the whole pleadings

3) Specific determination

위 인정사실과 변론 전체의 취지로부터 알 수 있는 다음과 같은 사정들, 즉 피해자가 운전하는 차량 앞으로 좌회전을 하는 차량이 한 대 더 있었고 이 사건 교차로를 거의 통과할 즈음에 이 사건 교통사고가 발생한 것으로 보아 이 사건 교차로의 신호기가 적색으로 변경된 시각과 원고가 이 사건 교차로에 진입한 시각 사이에 적어도 3~4초 정도의 간격이 있었을 것으로 보이는 점, 원고가 진행방향의 신호를 주시하지 못하였다고 하더라도 옆 차로의 차들이 정차 중이었으므로 적색신호가 점등된 사실을 충분히 인지할 수 있었던 점, 원고가 입은 상해의 정도나 피해 차량이 충격으로 움직인 정도 등에 비추어 원고의 진행 속도가 상당히 빨랐던 것으로 보이는 점 등을 종합하여 보면, 이 사건 교통사고는 원고의 고의 또는 중대한 과실로 인한 범죄행위가 전적인 원인이 되거나 적어도 주된 원인이 되어 발생하였다고 할 것이므로, 국민건강보험법 제53조 제1항 제1호 에 따라 원고에 대한 보험급여를 제한함이 타당하다.

C. Sub-decision

The instant disposition is lawful.

3. Conclusion

Therefore, the claim of this case is dismissed as it is without merit, and it is so decided as per Disposition.

Judges Hong Pung-chul (Presiding Judge)