2014Na200282 Insurance proceeds

Dong Fire Insurance Co., Ltd.

A

Suwon District Court Decision 2013Gahap14913 Decided December 20, 2013

March 11, 2015

April 22, 2015

1. Revocation of a judgment of the first instance;

2. It is confirmed that the obligation of the Plaintiff to pay cancer diagnosis expenses and insurance money for cancer surgery expenses under an insurance contract listed in attached Form 2, which occurred due to an insured event listed in attached Form 1 against the Defendant does not exist in excess of KRW 2,60,000.

3. All costs of the lawsuit shall be borne by the defendant.

The text shall be as shown in the text.

1. Basic facts, 2. The plaintiff's assertion and judgment

The grounds for this part of this Court shall be the same as the corresponding part of the grounds for the judgment of the first instance (the main sentence of Article 420 of the Civil Procedure Act).

(b) Fact of recognition;

The following facts are acknowledged in full view of the results of the inquiries about the members in C of this Court into the following facts: Gap evidence Nos. 2, 3, 5, Eul evidence Nos. 1, 2, and 4; the results of the request for the examination of each of the medical records to the school rooms of the law of the law of the Seoul National University of Education:

1) Details of the diagnosis

(A) the internal border inspection;

C내과의원 소화기내과 전문의 D은 2012. 12. 27. 피고에 대한 위내시경, 대장내시경 검사를 시행하면서 직장에서 2개의 폴립[polyp, 용종(事腫)이라고도 한다. 주로 점막에 발생하는 버섯모양의 융기성 병변을 총칭한다]을 발견하고 절제하였으며, 직장 카르시 노이드 종양[carcinoid tumor, 유암종(類癌腫)이라고도 한다]을 의심하고, 2012. 12. 28. 재단법인 네오딘의학연구소(재단법인 씨젠의료재단으로 명칭이 변경되었다)에게 수술 과정에서 떼어낸 검체(0.8cm x 0.7㎝ × 0.6㎝ 크기와 0.2cm × 0.1cm × 0.1cm 크기의 2개 폴립 부분)에 대한 조직검사를 의뢰하였다.

(b) organizational pathology testing;

On December 31, 2012, 2012, based on the result of re-requesting Korea-U.S. clinical trials, the NAH medical research institute reported the result of organizational pathology test on December 31, 2012.According to the results of the results, pathological diagnosis is a 'inceptionary colonation for work place', 'inception for formation', 'inception for Kazine stalthod', and 'inceptionary observation results', 'inceptionary stalthod', 'inceptionary stalthod' (the wall is classified into stalth, stalth, stalth, stalth, stalth, stalth, and stalthod's stalth, which is divided into upper cell floor, stalth, stalth, stalth, and stalthod's stalth.

C) Diagnosis

On January 4, 2013, medical doctors D diagnosed the Kazon as a type on the basis of the results of the above organizational inspection, and diagnosed on January 16, 2013 as the Kazin Mazin (workplace Pszin) No. C20.

(ii) medical assessment of workplace cancer;

A) The species of Kaurine Round are the species of neurine fluor, NET, and there was controversy as to whether it was malicious species, boundaryal species, and training species.

B) In the classification of the World Health Organization(WHO) under the United Nations in the past, it seems that the Kauro World constitutes the grade type code in the case of the Kauro World, which is classified into /3. However, based on the results of epidemological research, the WHO recently presented that the grade I, grade II, and grade IV, which correspond to the grade II, which correspond to the gradity of low level, which correspond to the grade I, and high level of badness.

C) The Korean Standard Disease Classification and Private Person Classification are in accordance with the WHO’s International Disease Classification System as data systematically tampling disease recovery and death data, such as mandatory recording data and statistical surveys on the cause of death, according to their similaritys in Korea.

Korean Standard Disease Classification 2, Part 3, Part 1, Part 2, Part 4, Part 3, Part 2, Part 4, Part 3, Part 4, Part 4, Part 3, an integrated classification number according to the International Disease Classification (ICD-O) for the climatic classification of new life. Part 3, Part 4, the malicious life of the firefighting engine is classified as C15-C26, Part 3, 320 is 4, 4, 5, 5, 5, 5, 5, 4, 5, 5, 5, 5, 5, 5, 5, 4, 5, 5, 5, 5, 4, 5, 5, 4, 5, 5, 4, 5, 5, 4, 5, 5, 5, 4, 5, 5, 4, 5, 4, 5, 4, 5, 4, 4, 5, 4, 4.

The Korean Standard Disease Classification did not mention the criteria for the distinction between badness and training or the diversity of boundary, and the distinction between them is based on the judgment of a medical specialist.According to the standards presented in the paper of 2008 and the paper of 2012 prepared by the Korean Medical Association in 201 by referring to foreign data, the Korean Medical Association suggested that the Korean Medical Association's admission to the registration of cancer of fire-fighting machinery for the pathology (Lcll for the pathology) in the workplace is less than 1 mm of large cells (Lcll) and GI and there is no blood-related invasion, the boundary-type 1'the behavior-type diversity diversity-type 2013 Ma205185.

3) Opinions on diagnosis of the Defendant

A) The results of the inquiry about C's doctor D

In the case of workplace-type cancer, GI and there is no blood ties less than 1cm, it is classified into ICD-O-3 classification and /1 commonly applied in the proposal of the Korea Sysiology registration guidelines, i.e., in cases where training or maliciously sensitive, and in such cases, it seems that the Korean standard disease and death classification code is d37 corresponding to 'unchranor' or ‘new life'. However, according to some research reports, in the case of cancer of less than 1cm with no risk factor, it is found that the crym code is found in 1.7-3.4%, and in other studies, the crym code is not 1.5-1.0cm with 0cm with 0% with 0% with 0.2% with 13.2% with 10% with 0.2% with 0.0% with 0.0% with 0.0% with 0.0% with 0.0% with 0.0% with 0.2% with 0.0.2% with 0.0.2% with 2% new cancer.

In the Korean Fire Fighting Association (Korean Fire Fighting Association), the C Code (29.2%), D01 (8.4%), D37 (53.1%) and D12 (8.9%) were applied to the genetic cancer that is observed in the workplace, and the C Code is assigned regardless of the size of the genetic cancer (26%), the C Code is assigned (4.6%) and the C Code is assigned from 6m or more to 3m more than 10m more (4.9%) and there is a need to establish standards between clinical and pathists.

Considering that the classification of Korean standard diseases and private persons presented by the Syuriology Association is basically a tool developed for statistical work with the basis for the pathology, it is a problem that clinical significance will be added to the judgment of severe diseases.

B) Following the Plaintiff’s request, the result of the commission of the medical record appraisal to the medical consultation reply reply from February 4, 2013 and the school room of the law of the Seoul University’s law

Considering the fact that the possibility of malicious transfer of small kermanian species found to be breeding species or prone cannot be completely ruled out, continuous progress observation is required, and that the level of maliciousity has been agreed to provide at least /1 in the form of an international disease classification code, the disease classification number is equivalent to d37.5, and typeological classification number falls under m. 8240/1. The size is 0.8cm x 0.7cm x 0.6cm x 0.6cm (the m. is deemed to have been smaller than that of the m.) surrounding organization, and there is no opinion of malicious species, the defendant's mar is a boundary pattern as a private person, and there is no opinion of malicious species.

C. Determination

위 인정사실에 의하여 알 수 있는 다음 사정, ① 이 사건 보험계약의 약관은 암과 경계성 종양의 분류기준으로 한국표준질병.사인분류의 분류기준과 그 용어만을 인용하고 있는데, 한국표준질병 · 사인분류의 분류번호 C15-C26의 '소화기관의 악성신생물'의 경우 암으로, 분류번호 D37의 '구강 및 소화기관의 행동양식 불명 또는 미상의 신생물'의 경우 경계성 종양으로 정의하고 있는 점, ② 조직병리검사결과 피고에게 발견된 카르시 노이드 종양의 크기는 0.8㎝ × 0.7cm × 0.6m와 0.2㎝ × 0.1cm × 0.1cm에 불과하고, 절제면을 고려하면 이보다 더 작다는 것이며, 검사결과 주변 조직의 침윤이나 원격 전이를 비롯한 악성을 시사하는 특별한 이상 소견은 발견되지 않은 점, ③ 이 사건 보험계약의 약관에 의하면 진단확정은 해부병리 또는 임상병리의 전문의사 자격증을 가진자에 의하여 내려져야 하고, 위 병리학적 진단이 가능하지 않을 때 임상학적 진단이 증거로 된다고 규정하고 있으므로, 병리학적 진단이 우선적으로 고려되어야 할 것으로 보이는데, 조직병리검사를 담당하였던 재단법인 네오딘의학연구소의 의사나 재의뢰를 받은 한미임상은 카르시노이드 종양으로 진단하였을 뿐 어느 한국표준질병·사인분류에 해당하는지에 관하여 언급하지 않았으나, 병리학적 진단이 가능하지 않은 상황이라고 보기 어려운 점, ④ 한국표준질병 · 사인분류 제4편은 항목분류 D37에 상응하는 행동양식 분류 '/1'을 양성 또는 악성 여부가 불확실한, 경계형 악성, 낮은 악성 잠재성, 불확실한 악성 잠재성으로, 항목분류 C20에 상응하는 행동양식 분류 '/3'을 악성으로 구분하고 있는데, 직장 유암종은 악성도 아니고 양성도 아닌 모호한 행동양식을 가지고 있고 크기가 1cm 미만의 경우는 드물지만 잠재적으로 악성의 경과를 보일 가능성, 즉 낮은 악성 잠재성이 있다는 것이므로 피고의 카르시노이드 종양(직장 유암종)은 위 행동양식 분류에 따를 때 '/3'이 아닌 '/1'을 부여하는 것이 위 용어에 충실한 해석으로 보이는 점, ⑤ 한국표준질병.사인분류는 불확실한 악성 잠재성의 카르시노이드 종양에 형태코드 M8240/1을, 카르시노이드 종양(충수 M8240/1 제외)에 형태코드 M8240/3을 각 부여하고, 종양은 크기, 혈관침범, 전이, 분화도 등에 따라 악성, 양성 또는 경계성으로 나뉘는데, 종양의 구체적 성질을 불문하고 직장의 모든 카르시노이드 종양에 형태코드 M8240/3을 부여하면 한국표준질병·사인분류의 위 구분이 무의미하게 되는 점, ⑥ 임상의와 병리학 자들간에 한국표준질병 · 사인분류의 C20을 적용할지, D37.5를 적용할지를 두고 논란이 있으나, 대한병리학회가 외국의 자료를 참고하여 제시한 기준에 의하면 피고에 대한 카르시노이드 종양은 경계성 종양에 해당하여 한국표준질병.사인분류 D37.5을 적용하는 것이 타당해 보이고, 원고의 의료자문회신 및 서울대학교 의과대학 법의학교실에 대한 진료기록감정촉탁결과도 같은 입장에 서 있는 점, ⑦ C내과의원 소화기내과 의사 D이 당초 피고에 대하여 한국표준질병 · 사인분류의 C20에 해당한다고 진단한 것은 병리학적 진단이 아닌 임상학적 진단에 해당하는데, 사실조회 회신에서 ICD-O-3 분류 및 대한병리학회 암등록 지침 제안의 입장을 받아들인다면 한국표준질병·사인분류 D37를 적용하는 것이 옳아 보인다는 입장을 표명하였고, 이는 병리학적 진단 차원에서는 D37로 분류하는 것이 보다 타당하다는 의견으로 보이는 점 등에 비추어 보면, 피고의 질병은 한국표준질병 · 사인분류의 분류기준에 의할 때 행동양식 분류번호 '/1'이 부여되는 불확실한 악성 잠재성의 카르시노이드 종양으로서 '직장에 있는 행동양식 불명의 신생물(D37.5)'로 정의되는 경계성 종양으로 보는 것이 상당하고, 이 사건 보험계약의 약관에서 정한 바에 따라 피고가 한국표준질병·사인분류 '악성신생물(C20)'인 병명으로 진단확정을 받았다고 보기 어렵다 [대법원 2013. 7. 25 선고 2012다82428 판결(카르시 노이드 종양이 0.3㎝의 크기이고 점막근층까지 침윤한 사안), 대법원 2013. 7. 25 선고 2013다202786 판결(카르시노이드 종양이 0.8cm X 0.6cm × 0.6㎝의 크기이고 점막층과 점막하층에 분포한 사안)도 참조].

The Defendant asserts to the effect that the terms and conditions of the instant insurance contract should be interpreted favorably to the Defendant. However, it is difficult to view that the content of the instant insurance contract may receive insurance proceeds from the insured, respectively, after undergoing an objective examination from a person holding a professional doctor’s license, after receiving a final diagnosis in accordance with the general medical standards. Thus, the Defendant’s assertion is without merit.

Therefore, the plaintiff recognized the defendant's disease as a type of boundary cultivation and sought the non-existence of an insurance claim exceeding KRW 2,600,000 on the premise that the insurance money is KRW 2,600,000, and there is a benefit of confirmation as long as the defendant disputes this.

3. Conclusion

Therefore, the plaintiff's claim is justified, and the judgment of the court of first instance is unfair, so the judgment of the court of first instance is revoked, and there is no obligation to pay insurance amount exceeding 2,60,000 won.

Judges or higher-ranking judges

Judge Oral Rule

Judges Hong Man-man

A person shall be appointed.