2015Na31071 Insurance proceeds

00

Insurance Corporation

Daegu District Court Decision 2015Na21165 Decided November 25, 2015

June 30, 2016

July 21, 2016

1. The plaintiff's appeal is dismissed.

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

The judgment of the first instance shall be revoked. The defendant shall pay to the plaintiff 41,200,000 won with 20% interest per annum from the day after the delivery of a copy of the complaint of this case to the day of complete payment.

1. Basic facts

A. On January 5, 2000, the Defendant entered into a family patriotism insurance contract with the state of the insured as the Plaintiff, with the insurance period from January 5, 2000 to January 5, 2020, and with the purchase amount of the State insurance as KRW 10 million as a major adult disease for the state of the insured. The Defendant entered into a family patriotism insurance contract with the state of the state of the insured with the content that it shall pay the agreed insurance money if the diagnosis is finalized as a "major adult disease" (hereinafter the “instant insurance contract”).

B. The main parts of the instant insurance contract relating to the instant case are as follows (hereinafter “instant insurance contract”).

Article 2 (Definition and Determination of Major Adult Diseases)

(1) In this contract, the term “major adult disease” refers to a disease falling under the following in the terms of “westhy’s 12 diseases” (see attached Table 2 “The Twesthy’s 12th disease classification table” and “Masyman’s 12nd disease classification table” and attached Table 4 “Masyman’s 12nd disease classification table”.

4. The term "cerebrovascular disease" refers to a disease classified as a cerebrovascular disease in the basic classification of the Korea Standard Classification of Diseases. In addition, the term "cerebrscular disease" in the "Korea Standard Classification of Diseases means a disease classified as a cerebrscular disease. From among the cerebrscular disease in the Korea Standard Classification of Diseases, the term "cerebrscular disease" refers to a salphalopia, cerebral cerebrscular, and other non-cerebrscular two, cerebrscular, cerebrscular, cerebrscular, and cerebrscular color (the classification number 160-163, 165-166). Article 4 (Definition and Place of Hospitalization)

In this contract, the term "hospitalize" means entering a hospital or a clinic as provided in Article 3(2) of the Medical Service Act, or a foreign medical institution recognized by the company as equivalent thereto, in which it is deemed necessary to provide medical treatment due to "major adult disease", "a dentist or a person qualified as an oriental medical doctor" (hereinafter referred to as "the doctor"), and it is difficult to provide medical treatment at his own home, etc., and concentrate on the care under the control of the doctor.

(1) If any of the following events occurs during the period of insurance, the Company shall pay the insured money agreed upon to the beneficiary (see attached Table 1, e.g., attached hereto):

1. When the insured was diagnosed for the first time after the starting date of responsibility for the first time as "major adult disease" or "major adult disease" or "major adult disease", and continued to be hospitalized for at least 181 days after hospitalization for the direct purpose of treating 31 days, 121 days or no less than 40 days and 181 days for the purpose of treating the cryp cancer or the cump cancer ( even if the company is hospitalized by relocating the hospital or the clinic, it shall be deemed that the person was hospitalized continuously if it is recognized by the company), and discharged him/her after the discharge: Payment of health and living expenses;

3. Where the insured person first is diagnosed as a "major adult disease" or a "major adult disease" or a "major adult disease" or continued to be hospitalized for at least four consecutive days for the direct purpose of treating his/her upper cancer after the date of commencement of responsibility: Payment of hospitalization expenses;

(3) In the case of paragraph (1) 3, where the insured has been hospitalized not less than 4 days for the purpose of directly treating the same “major adult disease” or the upper cancer not less than 4 days, the number of days of hospitalization shall be considered as one time and added up. However, even if hospitalization was conducted by the same “major adult disease” or the upper cancer cancer, if re-hospitalizes after the lapse of 180 days from the date of discharge of the final hospitalization for which the hospitalization was paid, the new hospitalization shall be deemed to be a new hospitalization. In the Korean Standard Disease Classification in the 12th Standard disease Classification Clause of Hyundai 12th, Hyundai 12th, in accordance with the Korean Standard Disease Classification Clause of 12th, Hyundai 12th, the disease classified as one of the 3th revised Korean Standard Disease Classification (Notice No. 1993-3 of Statistics Korea, January 1, 1995) refers to the disease next to the following.

A person shall be appointed.

C. When applying to the insurance contract of this case, healthy living expenses and reasons for the payment of hospitalization expenses and the amount payable are as follows:

A person shall be appointed.

D. Around May 201, the Plaintiff suffered from cerebral blood, and received hospitalization expenses from the Defendant as follows.

A person shall be appointed.

E. From January 2, 2014 to July 2, 2014, and from July 4, 2014 to May 15, 2015, the Plaintiff was hospitalized in a hospital specializing in Gyeongbuk-do (hereinafter “instant hospitalization”) due to the diagnosis of cerebrovascular surgery, part-time paralysis, verbal disorder, etc., in each hospital specializing in Gyeongbuk-do from July 4, 2014 to 15.

[Reasons for Recognition] Facts without dispute, Gap evidence 1, 3, 6 (including branch numbers), Eul evidence 1 and 4, the purport of the whole pleadings

2. Determination as to the cause of action

A. The plaintiff's assertion

In relation to the instant hospitalization, the Plaintiff sought payment of KRW 7,20,000 as the insurance money (i.e., KRW 30,000 won X 120 x twice) and the amount of KRW 34,00,00 as the cost of healthy living (i.e., at least 181 days of hospitalization) (i.e., KRW 17,000 x 2 times of hospitalization), and damages for delay.

B. Determination

1) “Hospitalization for the direct purpose of medical treatment” under the instant insurance contract refers to receiving hospitalized treatment under the observation and management of a doctor in order to improve the serious military symptoms that have arisen directly due to a disease itself or a disease. Therefore, it is difficult to deem that the treatment of a person after the completion of the treatment is alleviated, or that medical treatment for the treatment of a merger is also included in the concept of hospitalization (see Supreme Court Decision 2010Da40543, Sept. 30, 2010).

In addition, in a case where continuous observation by a medical personnel is required with respect to side effects or incidental effects of drugs which have low resistance power on a patient's disease or are administered, in a case where it is necessary to continuously administer medication and food, and thus, it is necessary to continuously administer medication and treatment, and thus, the patient's pains rather inconvenience in treating the patient, such as where the patient's condition is in a situation where the patient's condition is unable to cope with pain or where the patient's risk of infection exists, etc., and where the patient is staying in the hospital, it means receiving treatment under the observation and management of the medical personnel while the patient stays in the hospital for more than six hours pursuant to the "detaileds on the criteria and methods for applying medical care benefits as notified by the Ministry of Health and Welfare" (see Supreme Court Decision 2004Do6557, Jan. 12, 206). However, the determination should be made by comprehensively taking into account the symptoms, diagnosis and treatment of the patient, the patient's behavior, etc. (see Supreme Court Decision 2004Do657).

2) In full view of the purport of the argument as to whether the instant hospitalization was made directly for the purpose of treatment of cerebrovascular, the written evidence Nos. 2, 4, 7, 8, and 9, and the fact-finding on the convalescent hospital by the court of first instance, the Plaintiff was unable to walk because the Plaintiff had no ability to walk as to hye and hye due to cerebrs aftermathy, etc. due to cerebrscular, and the fact-finding that the Plaintiff was in need of rehabilitation treatment to maintain her physical function, respectively.

However, in light of the above legal principles, Gap evidence Nos. 2 and 5, Eul evidence Nos. 2, and Eul evidence Nos. 2, and each fact-finding with respect to the department of rehabilitation at the university hospital at the court of first instance and the hospital specializing in the elderly, the following circumstances acknowledged comprehensively based on the whole purport of the arguments, namely, ① the plaintiff was engaged in several outing and going outing out of the country during the instant hospitalization, ② it is difficult to expect a large number of defenses during three years after the outbreak of cerebrovascular, ② it is necessary to conduct hospital for rehabilitation treatment, ③ there is no evidence to prove that the plaintiff was hospitalized with any other significant military register in relation to cerebrovascular at the time of the instant hospitalization, and there is no evidence to acknowledge that the instant hospitalization constitutes hospitalization for the direct purpose of treating major adult diseases or diseases, and there is no evidence to prove otherwise.

3) As to this, the Plaintiff asserts that the medical treatment, etc. for relaxation of post-cerebrovascular is not included in “hospitalize for the direct purpose of treatment.” However, this is limited to post-treatment arising from treatment methods used in the process of treatment for cerebrovascular. Thus, the Plaintiff asserts that hospitalization for cerebrscular is included in “hospitalize for the direct purpose of treatment of cerebrscular.”

However, it is difficult to interpret the "medical practice to alleviate post-treatment" that is not included in the grounds for payment of insurance proceeds. It is difficult to say that only the post-treatment is caused by the treatment method.

4) Therefore, the Plaintiff’s instant hospitalization cannot be deemed to constitute grounds for payment of healthy living expenses and hospitalization expenses according to the instant insurance contract. Therefore, the Plaintiff’s claim of this case premised on this cannot be justified.

3. Conclusion

Therefore, the plaintiff's claim of this case is dismissed as it is without merit, and the judgment of the court of first instance is just in conclusion, and the plaintiff's appeal is dismissed. It is so decided as per Disposition.

Allowable judge of the presiding judge

Judges Oo-crimes

delay by the judge