2019Da279962 Payment of motor vehicle insurance medical fees

Plaintiff 1 and six others

Law Firm Hamdong, Counsel for the plaintiff-appellant

[Defendant-Appellant] The Head of Sin Chang-gu Office

The Federation of National Private Taxi Transportation Business Associations

Law Firm Dop, Counsel for the plaintiff-appellant

Attorney Dong-young et al., Counsel for defendant-appellee

Seoul High Court Decision 2017Na2069695 Decided September 27, 2019

December 10, 2020

All appeals are dismissed.

The costs of appeal are assessed against the defendant.

The grounds of appeal are examined.

1. Case summary and key issue

A. The reasoning of the lower judgment reveals the following circumstances.

(1) The plaintiffs are medical specialists in film and video who operate a film department, and the defendant is a private taxi mutual aid business operator.

(2) If a medical institution receives the insurance money (including mutual aid money; hereinafter referred to as "insurance money, etc.") from an insurance company (including a mutual aid business operator; hereinafter referred to as "insurance money, etc.") for the medical treatment of a person who suffered an accident caused by the operation of a motor vehicle (hereinafter referred to as "motor vehicle accident patient"), the amount calculated according to the provisions of the Guarantee of Automobile Accident Compensation Act (hereinafter referred to as "Act on the Guarantee of Automobile Accident Compensation") shall be paid, and it shall be called "motor vehicle insurance medical fees" (Article 2 subparagraph 7 (a) of the Automobile Accident Compensation Act).

(3) The Plaintiffs, upon receiving a request from another medical institution for medical treatment for patients suffering from a traffic accident, conducted visual reading service using the Computerization-based photographing device (CT), one’s own official image photographer (MRI), and two-electronic body imageer (PET). Before the amendment of the Automobile Loss Compensation Act in 2012, the Plaintiffs directly filed a claim for motor vehicle insurance medical fees with the insurer, etc., and the insurer, etc. directly filed a claim for motor vehicle insurance medical fees with the insurer, etc., and paid motor vehicle insurance medical fees to the Plaintiffs following the procedure for the mediation of the Motor Vehicle Accident Compensation Insurance Dispute Resolution Council.

(4) Following the amendment of the Automobile Loss Act by Act No. 11369, Feb. 22, 2012, insurance companies, etc. pursuant to Article 12-2, which was newly established pursuant to Article 12-2, can entrust the review and adjustment of motor vehicle insurance medical fees to the Health Insurance Review and Assessment Service, which is a specialized review agency. The Health Insurance and Assessment Service entered into a contract with insurance companies, etc. including the Defendant on June 14, 2013, and had them take charge of the review of motor vehicle insurance medical fees from July 1, 201

(5) On June 4, 2013, the president of the Health Insurance Review and Assessment Service publicly announced the detailed summary of preparing a written claim for and detailed statement of motor vehicle insurance medical fees (Health Insurance Review and Assessment Service Notice No. 2013-85), among which, in the item â…………………, the summary of preparing the statement of medical fees; â…………â…………, details of the diagnosis and assessment;â…………………â………â………â……â……â……â……â………ââ……â………âââ………âââ………âââââââââ………âââââ………âââââââââââââââ…………âââââ

(6) The Plaintiffs requested the treatment of traffic accident patients hospitalized in other medical institutions as shown in the claim list against the Defendant in attached Forms 3 and 4 of the lower judgment, and provided the aforementioned examination request system to the Health Insurance Review and Assessment Service, such as video photographing and video reading. In this regard, the Plaintiffs received each notification from the Defendant that the Defendant should pay the medical expenses according to the standard pursuant to Article 12(1) of the Automobile Loss Compensation Act around that time.

(7) The Plaintiffs directly filed a claim for the payment of motor vehicle insurance medical fees with the Health Insurance Review and Assessment Service, in order that the medical institutions requesting treatment did not file a claim for the payment of motor vehicle insurance medical fees according to the outpatients medical treatment

(8) The Health Insurance Review and Assessment Service rendered a decision on the impossibility of review and the revocation of review on the ground that the plaintiffs are not the claimant as stipulated in the announcement clause of this case, and the plaintiffs filed the lawsuit of this case seeking direct payment of motor vehicle insurance medical fees

B. The key issue of the instant case is whether the medical institution providing medical treatment can directly seek reimbursement for motor vehicle insurance medical fees under the Motor Vehicle Loss Compensation Act against the insurer, etc., and in this regard, the issue is whether the said provision has the effect of binding the Plaintiffs or the Defendant.

2. Method of exercising the claim for motor vehicle insurance medical fees;

(a)the method of exercise in principle;

(1) According to the Motor Vehicle Liability Act, when the medical institution that provided medical treatment to a motor vehicle accident patient is notified by the insurer, etc. of its intent to pay motor vehicle insurance medical fees according to the pertinent medical treatment and the payment limit thereof, the insurer, etc. may claim the fees for motor vehicle insurance calculated in accordance with the standards determined and publicly notified by the Minister of Land, Infrastructure and Transport pursuant to Article 15 (Article 12(1) and (2). The insurer, etc. may entrust the examination and adjustment of motor vehicle insurance medical fees claimed by the medical institution to a specialized examination institution prescribed by Presidential Decree (Article 12-2(1)). In such cases, the specialized examination institution shall examine whether the medical fees claimed by the medical institution meet the standards for

Where an insurer, etc. has entrusted a specialized examination institution with the review and adjustment of motor vehicle insurance medical fees, etc., it shall pay motor vehicle insurance medical fees according to the results of such review within 14 days from the date when the specialized examination institution notifies of the results of such review (Article 12 (4)); where an insurer, etc. has entrusted a specialized examination institution, the insurer, etc. and medical institution may, upon receipt of notification of the results of such review under Article 12-2 (2), request an examination to the Council of Motor Vehicle Insurance Medical Fees (Article 19 (1) and Article 12-2 (1) within 30 days from the date when it receives notification of the results of such objection (Article 19 (3)), and the insurer, etc. and medical institution in receipt of notification of the results of the review of the specialized examination institution under paragraph (1) shall be deemed to have reached an agreement on the details or results of such examination requested by the medical institution on the date when the period expires (Article 19 (1) 19 (2) ); if the Council of Motor Vehicle Insurance Medical Fees has not received notification of such results from the parties within 20 days after receipt.

(2) According to Article 11-2 of the Enforcement Decree of the Automobile Accident Compensation Act, “specialized examination institution” refers to the Health Insurance Review and Assessment Service. According to the Enforcement Rule of the Automobile Accident Compensation Act, when an insurer, etc. has entrusted the review, adjustment, etc. of motor vehicle insurance medical fees to the Health Insurance Review and Assessment Service, the medical institution shall file a claim for motor vehicle insurance medical fees with the Health Insurance Review and Assessment Service (Article 6-2(1)); when the Health Insurance Review and Assessment Service receives a claim for motor vehicle insurance medical fees from the medical institution, it shall notify the relevant insurer, etc. of the fact that the claim was filed (Article 6-2(2)); and (1) of the fact that the details of the claim comply with the standards on the medical fees of motor vehicle insurance premiums under Article 15(1) of the Motor Vehicle Accident Compensation Act (Article 6-3(1)); and (3) the insurer, etc. shall notify the relevant medical institution and insurer, etc. of the results of the examination thereof within 15 days of the claim (Article 6-3(4).

(3) In full view of the above provisions, where an insurance company, etc. has notified its intention to pay for motor vehicle insurance medical fees and its payment limit pursuant to Article 12(1) of the Motor Vehicle Loss Act, the medical institution which provided medical treatment for motor vehicle accident patients has the right to file a claim for motor vehicle insurance medical fees with the insurance company, etc. in accordance with the standards determined and publicly notified by the Minister of Land, Infrastructure and Transport pursuant to Article 15 of the Motor Vehicle Loss Compensation Act, and where the insurance company, etc. entrusted the Health Insurance Review and Assessment Service with the examination and Assessment Service with the examination and Assessment Service with the examination and assessment service, it shall exercise the right to claim for motor vehicle insurance medical fees by submitting a claim to the Health Insurance Review and Assessment Service. If the results of the examination and assessment of the medical institution’s claim or the

(b) Methods of exercising the medical institution's claim where the Health Insurance Review and Assessment Service rejects substantive examination.

(1) Article 6-5 of the Enforcement Rule of the Automobile Accident Compensation Act provides that the Minister of Land, Infrastructure and Transport shall determine and publicly announce detailed matters necessary for the filing, examination, payment, objection, etc. of motor vehicle insurance medical fees entrusted to the Health Insurance Review and Assessment Service. Accordingly, the Minister of Land, Infrastructure and Transport established the Regulations on the Review and Assessment of Motor Vehicle Insurance (Notice No. 2013-224 of the Ministry of Land, Infrastructure and Transport, May 9, 2013, hereinafter referred to as the "Notification") for the purpose of prescribing the procedures and methods for filing, examination, payment, and objection, etc. of motor vehicle insurance medical fees entrusted to the Health Insurance Review and Assessment Service, and the procedure for filing a request for review of the Motor Vehicle Insurance Medical Fees Review and Assessment Service (hereinafter referred to as the "Notification" in this case"). The Notification in this case provides for the forms that the medical institution and the Health Insurance Review and Assessment Service may use in relation to the filing of medical fees and its review thereof in writing under Article 20 (1).

As can be seen, Articles 11 and 12 of the Notice of this case provide that uniform forms shall be used in order to promote the filing of claims for motor vehicle insurance medical fees of medical institutions and the convenience and efficiency of review by the Health Insurance Review and Assessment Service. However, the guidelines for preparing a written request in accordance with the form shall be an explanation about the method of using the form and shall not be deemed a law that regulates the rights and obligations of the people. In addition, Article 20(8) of the Notice of this case only provides that only the detailed preparation guidelines that are not prescribed in the separate 1 and 2 guidelines may be prescribed by the Health Insurance Review and Assessment Service. Accordingly, the "detailed preparation guidelines" prescribed by the head of the Health Insurance Review and Assessment Service of the Health Insurance Review and Assessment Service shall be more detailed than the method of using the forms prescribed in Articles 11 and 12 of the Notice

(2) On a business entrustment agreement entered into with the Insurance Review and Assessment Service, including the Insurance Company and the Defendant, the Insurance Company and the Insurance Company, etc., there is no provision that limits or allows the Insurance Review and Assessment Service, etc. to choose the medical institutions to claim for motor vehicle insurance medical fees, which are in the position of performing duties of review and adjustment of the fees for motor vehicle insurance, by which the Insurance Company, etc. may request the Insurance Review and Assessment Service to grant the authority under the law or the contract. Nevertheless, the instant provision limits the claimant for motor vehicle insurance medical fees by providing that the medical institution requesting the medical treatment requests the medical institution to provide medical fees, and that the medical institution providing the medical treatment cannot claim for motor vehicle insurance fees, and that the medical institution providing the medical treatment restricts the claimant for motor vehicle insurance medical fees by providing that the medical institution shall not claim for motor vehicle insurance fees for motor vehicle insurance fees. This goes beyond the limit of the literal meaning of "the detailed statement prepared",

(3) As seen earlier, if the insurer, etc. notified the insurer, etc. of its intention to pay for motor vehicle insurance medical fees and its payment limit under Article 12(1) of the Motor Vehicle Loss Act, the insurer, etc. shall obtain the right to claim for motor vehicle insurance medical fees calculated in accordance with the criteria determined and publicly notified by the Minister of Land, Infrastructure and Transport pursuant to Article 15 of the Motor Vehicle Loss Compensation Act, and if the Health Insurance Review and Assessment Service claims for motor vehicle insurance medical fees, it shall be deemed that the method of exercising the right to claim for motor vehicle medical fees provided by the Motor Vehicle Loss Compensation Act has been complied with. The Health Insurance Review and Assessment Service is performing the business of examining motor vehicle insurance medical fees entrusted by the insurer, etc. under the business entrustment agreement with the insurer, etc..

Nevertheless, in a case where the Health Insurance Review and Assessment Service unilaterally provides internal provisions made for its business convenience and efficiency, such as the instant announcement provision, and thus refuses to review the substantive claim, it is necessary for an insurer, etc. to urge the Health Insurance Review and Assessment Service to comply with the entrustment contract. However, if the Insurance Association does not take such measures, the medical institution providing the medical examination and Assessment Service may directly claim for the payment of motor vehicle insurance medical fees to the insurance company, etc.

3. Determination as to the instant case

A. The lower court determined that the medical institution providing medical treatment can claim for payment of motor vehicle insurance medical fees directly to the insurer, etc. without undergoing the procedure for claiming for motor vehicle insurance medical fees by the Health Insurance Review and Assessment Service, on the ground that the medical institution providing medical treatment claims for motor vehicle insurance medical fees to the Health Insurance Review and Assessment Service without any legal basis, but it is not limited to the claims for motor vehicle insurance medical fees by the medical institution providing medical treatment under the publicly notified provision of this case, but where the Health Insurance Review and Assessment Service refused substantive examination on the ground of the publicly notified provision of

B. Examining the reasoning and records of the lower judgment in light of the aforementioned legal doctrine, such determination by the lower court is justifiable, and contrary to what is alleged in the grounds of appeal, the lower court did not err by misapprehending the legal doctrine on the medical institution’s claim for medical

4. Conclusion

Therefore, all appeals are dismissed, and the costs of appeal are assessed against the losing party. It is so decided as per Disposition by the assent of all participating Justices on the bench.

Justices Kim Jae-hwan

Justices Park Sang-ok