2014Na3355 Undue gains

National Health Insurance Corporation

Korea Labor Welfare Corporation

Chuncheon District Court Decision 2014 Ghana56105 Decided June 13, 2014

March 20, 2015

April 10, 2015

1. Of the judgment of the court of first instance, the part against the defendant in excess of the money ordered to be paid below shall be revoked and the plaintiff's claim corresponding to the revoked part shall

The defendant shall pay to the plaintiff 137,630 won with 5% interest per annum from December 23, 2011 to April 10, 2015, and 20% interest per annum from the next day to the day of full payment.

2. The defendant's remaining appeal is dismissed.

3. 1/10 of the total costs of litigation shall be borne by the Plaintiff, and the remainder by the Defendant, respectively.

1. Purport of claim

The defendant shall pay to the plaintiff 137,630 won with 5% interest per annum from July 21, 201 to the service date of a copy of the complaint of this case, and 20% interest per annum from the next day to the day of complete payment.

2. Purport of appeal

The judgment of the first instance is revoked. The plaintiff's claim is dismissed.

1. Basic facts

A. A worked as an employee of New Co., Ltd., and received medical treatment in B, etc. from May 16, 201 to May 20, 201, by suffering from injury to the reputation of “other descendants and descendants” due to their occupational negligence (hereinafter “instant injury”).

B. As above, the Plaintiff paid KRW 137,630 to the relevant medical care institution out of the medical care costs incurred by A in receiving medical treatment in the medical care institution.

C. A asserted that the instant injury to the Defendant was an occupational accident and filed an application for medical care benefits with the Defendant. On June 3, 2011, the Defendant rendered a decision on the approval of industrial accidents against A.

D. Meanwhile, on May 16, 201, A received KRW 300,00 from New Co., Ltd., a business owner, and drafted a second written agreement on the injury and disease of this case. The said written agreement states as follows: “I agree that the compensation for treatment costs shall be completed with the agreed amount, and that I will not thereafter make any legal and objection thereto,” and “I agree that I will not make any legal and objection thereto later.”

【Fact-finding without a dispute over the grounds for recognition, Gap evidence 3 and Eul evidence 1 and 2, the purport of the whole pleadings

2. The assertion and judgment

A. The parties' assertion and the issues of this case

1) The Plaintiff asserts that, from May 16, 201 to May 20, 201, the Plaintiff was obligated to settle the costs of medical care benefits to the Plaintiff pursuant to Articles 90(1) and 42(1) of the former Industrial Accident Compensation Insurance Act (amended by Act No. 11141, Dec. 31, 201; hereinafter “former Industrial Accident Compensation Insurance Act”).

2) On May 16, 201, prior to the Plaintiff’s provision of medical care benefits to A, the Defendant asserted that, by paying in advance the money and valuables equivalent to medical care benefits under the former Industrial Accident Insurance Act with respect to the instant injury and disease to A, the business owner has already subrogatedly acquired the right to claim insurance benefits against A pursuant to Article 89 of the former Industrial Accident Insurance Act, the Plaintiff cannot claim for the settlement of the relevant expenses against the Defendant on the ground that the medical care benefits that he/she provided to A thereafter are medical care benefits.

3) Therefore, the key issue of the instant case is whether the Plaintiff may claim the settlement of the expenses for the medical care benefits against the Defendant, in a case where the affected worker received the money and valuables from the business owner under the pretext of expenses for occupational accidents and the Defendant received the medical care benefits from the Plaintiff before the Defendant decided to approve the industrial accident for the affected worker.

B. Relevant statutes

It is as shown in the attached Form.

C. Determination

1) After the agreement with the employer, a claim for the settlement of the costs of medical care provided by the Plaintiff is filed.

A) Article 48(1)4 of the former National Health Insurance Act (wholly amended by Act No. 11141, Dec. 31, 2011; hereinafter the same shall apply) provides that "the National Health Insurance Corporation shall not provide any insurance benefits if a person entitled to receive such insurance benefits receives such insurance benefits under other Acts and subordinate statutes due to an occupational or occupational accident or an injury." Meanwhile, Article 42(1) of the former Industrial Accident Insurance Act provides that "the person who has filed an application for medical care benefits may receive medical care benefits under Article 39 of the National Health Insurance Act before the Korea Workers' Compensation and Welfare Service makes a decision on the medical care benefits under this Act." Article 90(1) of the same Act provides that "the National Health Insurance Corporation shall be entitled to medical care benefits under this Act, if it pays the health care benefits first to the beneficiary under this Act, and the National Health Insurance Corporation shall be entitled to receive such benefits after its decision on the payment of health care benefits under this Act, and the National Health Insurance Corporation shall pay the amount equivalent to the health care benefits under this Act."

As can be seen, the purport of the former Industrial Accident Insurance Act and the former National Health Insurance Act provides that the National Health Insurance Corporation may first provide medical care benefits and then claim the settlement of expenses incurred in relation to the provision of medical care benefits to the Workers’ Welfare Union until the Korea Workers’ Compensation and Welfare Service makes a decision on whether to accept an industrial accident after the application for medical care benefits, and that the Korea Workers’ Compensation and Welfare Service may claim the settlement of expenses incurred in relation to the provision of medical care benefits to the National Health Insurance Corporation after the Korea Workers’ Compensation and Welfare Service made a decision on whether to accept an industrial accident. The purport of the provision that the Korea Workers’ Compensation and Welfare Service may claim the settlement of expenses incurred in relation to the provision of medical care benefits to the National Health Insurance Corporation. Of the social insurance benefits for citizens, the portion caused by an industrial accident is provided through an industrial accident compensation insurance through the National Health Insurance Act, but even if it is unclear whether the worker’s disease or injury is caused by an industrial accident, the employee is provided once provided by the Korea Workers’ Compensation and Welfare Service or the National Health Insurance Corporation after the settlement of these expenses through a separate procedure.

B) Therefore, the phrase “where it is recognized that it is equivalent to the medical care benefits that can be paid pursuant to the former Industrial Accident Insurance Act or the former National Health Insurance Act” as stated in each of the above settlement provisions means the case meeting the requirements for payment of the medical care benefits prescribed under Article 40 of the former Industrial Accident Insurance Act and Article 41 of the former National Health Insurance Act. Unlike this, the beneficiary does not mean that the beneficiary actually claims the Korea Workers’ Compensation and Welfare Service or the Korea Workers’ Compensation and Welfare Service for the payment of the medical care benefits. Therefore, the beneficiary does not mean that the beneficiary falls under a case where the beneficiary is unable to receive the medical care benefits from the Korea Workers’ Compensation and Welfare Service pursuant to Article 80(3) of the former Industrial Accident Insurance Act, or where the business owner, who is an industrial accident insured, provided money and valuables equivalent to the medical care benefits to the accident workers who are the beneficiary, and subrogated to receive the insurance benefits pursuant to Article 89 of the former Industrial Accident Insurance Act, the Korea Workers’ Compensation and Welfare Service may make a double payment to the Korea Workers’ Compensation and Welfare Service pursuant to Article 81 of the former Industrial Accident Insurance Act.

On the contrary, if an employer has offered money and valuables equivalent to the insurance benefits to disaster workers, the National Health Insurance Corporation cannot claim the Korea Workers' Compensation and Welfare Service to settle the cost of the quantity for health care benefits already provided to disaster workers, the National Health Insurance Corporation, as it determines whether it is not entitled to receive the settlement of the cost of health care benefits from the Korea Workers' Compensation and Welfare Service due to an unexpected circumstance not known at the time of the subscription to health care benefits. Therefore, if the National Health Insurance Corporation provides health care benefits to disaster workers who have not yet received the approval of industrial accident from the Korea Workers' Compensation and Welfare Service to prevent unfair health care benefits, it is likely that there is a gap in providing social insurance benefits to disaster workers, and if it is necessary to confirm whether there is money and valuables received in advance from the employer every time when it provides health care benefits to the disaster workers who have not yet received the approval of industrial accident from the Korea Workers' Compensation and Welfare Service, and as such,

C) Therefore, the Defendant’s above assertion on a different premise is without merit, and the Plaintiff may claim for the settlement of medical care benefit costs against the Defendant regardless of whether A received the amount of KRW 300,000 from the Li business owner in the name of medical treatment.

2) Sub-determination

Therefore, the Defendant has the obligation to pay the expenses for medical care benefits that the Plaintiff first provided to the Plaintiff, and such obligation is an obligation for the Defendant’s settlement prohibition due to the absence of fixed payment deadline, so the Defendant is liable for delay from the time of receiving the claim for performance (see, e.g., Supreme Court Decisions 2009Da24187, 24194, Jan. 28, 2010; 2014Da21849, Dec. 24, 2014); and the Plaintiff claimed for the payment of the settlement amount against the Defendant on December 22, 2011; thus, there is no conflict between the parties, and the Defendant has the obligation to pay the payment amount at the rate of KRW 137,630, and damages for delay calculated from December 23, 2011 to the date following the claim for payment with respect to the existence and scope of the obligation to pay the payment amount at the rate of 10% per annum 200,50% per annum.

3. Conclusion

Therefore, the plaintiff's claim of this case shall be accepted within the above scope of recognition and its claim shall be dismissed for reasons without merit. Since the part against the defendant who ordered payment exceeding the above recognized amount among the judgment of the court of first instance is unfair, it shall be revoked, and the plaintiff's claim corresponding to the revoked part shall be dismissed, and the defendant's remaining appeal shall be dismissed for reasons. It is so decided as per Disposition.

Maximum amount (Presiding Judge)

Long-term Private Telecommunication

Ise Jina

Related Acts and subordinate statutes

former Industrial Accident Compensation Insurance Act (amended by Act No. 11141, Dec. 31, 201)

Article 36 (Types of Insurance Benefits, Standards for Calculation, etc.)

(1) The types of insurance benefits shall be as follows: Provided, That the types of insurance benefits for pneumoconiosis shall be required under subparagraph 1:

The nursing benefits, nursing benefits under subparagraph 4, funeral expenses under subparagraph 7, vocational rehabilitation benefits under subparagraph 8, medical treatment under Article 91-3;

Waste compensation annuities and pneumoconiosis survivors' annuities under Article 91-4 shall be the pneumoconiosis survivors' annuities.

1 Medical Care Benefits

2. Temporary layoff benefits;

3. Disability benefits:

4. Nursing benefits;

5. Survivors' benefits:

6. Injury and disease compensation annuities;

7. Funeral expenses;

8. Vocational rehabilitation benefits.

Article 40 (Medical Care Benefits)

(1) Medical care benefits shall be provided to any worker who suffers from an injury or disease caused by reason of his/her duties.

Payment shall be made.

(2) Medical care benefits referred to in paragraph (1) shall be provided to industrial accident insurance-related medical institutions referred to in Article 43 (1).

Provided, That where it is inevitable, medical care expenses may be paid in lieu of medical care.

(3) In cases under paragraph (1), if an injury or disease is to be cured through medical care within three days, medical care benefits shall be paid.

subsection (b) of this section.

(4) The scope of medical care benefits under paragraph (1) shall be as follows:

1. Diagnosis and examination;

2. Provision of medicines or diagnosis and treatment materials, artificial limbs and other prosthetic devices;

3. Treatment, operation and other medical care;

4.Retreatment

15. Hospitalization;

6. Nursing and nursing;

7. Transfer.

8. Other matters prescribed by Ordinance of the Ministry of Employment and Labor.

(5) The criteria for calculating medical care benefits referred to in paragraphs (2) and (4) shall be determined by Ordinance of the Ministry of Employment and Labor.

set forth in section 26(3).

* An industrial accident insurance-related medical institution that provides medical treatment to a worker suffering from an occupational accident shall be the prize under Article 43(1)(2).

In the case of an emergency general hospital, it shall be an emergency patient under subparagraph 1 of Article 2 of the Emergency Medical Service Act or such patient.

Unless there is any inevitable reason, the worker needs to receive medical care at a superior general hospital.

There should be a medical opinion that there is any medical opinion.

Article 41 (Application for Medical Care Benefits)

(1) Medical care benefits (excluding medical care benefits for pneumoconiosis; hereafter the same shall apply in this Article) referred to in Article 40 (1).

A person who intends to receive an employment contract shall have his/her workplace, circumstances of the occurrence of the accident, medical opinion about the accident, and other employment regulations.

An application for medical care benefits shall be filed with the Corporation, accompanied by documents stating matters prescribed by Ordinance of the Ministry of Information and Communication.

In such cases, procedures and methods for filing applications for medical care benefits shall be prescribed by Ordinance of Ministry of Employment

Article 42 (Preferential Application of Health Insurance)

(1) A person who applies for medical care benefits pursuant to Article 41(1) shall be determined by the Service as to medical care benefits under this Act.

Before making any circumstance, Article 39 of the National Health Insurance Act or Article 7 of the Medical Care Assistance Act shall apply.

Medical benefits under the Health Insurance, etc. (hereinafter referred to as "medical care benefits, etc.") may be provided.

Article 80 (Relation with Other Compensation or Indemnity)

(3) A beneficiary shall be reasonably entitled to insurance benefits under this Act for the same reason pursuant to the Civil Act or other statutes.

Upon receipt of money or valuables, the Corporation shall limit the amount converted into the money or valuables received in such manner as prescribed by Presidential Decree.

No insurance benefits referred to in this Act shall be paid to the Do: Provided, That the entitlement to insurance benefits pursuant to the latter part of paragraph (2).

Pension amount corresponding to lump-sum disability compensation benefits or lump-sum survivors' compensation benefits deemed to have been paid.

this provision shall not apply to any case.

Article 84 (Collection of Unjust Enrichment)

(1) If a person who has received insurance benefits falls under any of the following subparagraphs, the NHIS shall pay such benefits:

The amount (in the case of subparagraph 1, the amount equivalent to twice the amount of benefits) shall be collected. In this case, the amount shall be collected.

Provided, That the amount received from the National Health Insurance Corporation, etc. under Article 90 (2) shall be the amount collected.

excluding.

1. Where he/she has received the insurance benefits by fraud or other improper means;

2. A beneficiary or a former beneficiary shall file a report under Article 114 (2) through (4);

Where he/she has received an insurance benefit unfairly by failing to pay it;

3. Where there are other insurance benefits mistakenly paid.

(3) The Service shall cause an industrial accident insurance-related medical institution or pharmacy referred to in Article 46 (1) to fall under any of the following subparagraphs:

(2) In the case of subparagraph 1, an amount equivalent to the medical expenses or medicine expenses shall be collected.

The amount equivalent to twice the medical expenses or medicine expenses (where penalty surcharges are imposed pursuant to Article 44 (1)).

shall be collected in the amount equivalent to the medical expenses.

1. Where the medical expenses or medicine expenses are obtained by fraud or other improper means;

2. Unfair medical treatment, in violation of the criteria for calculation of medical care benefits under Articles 40 (5) and 91-9 (3);

When he/she receives expenses or medicine expenses;

3. Where the medical expenses or medicine expenses are obtained by mistake.

Article 85 (Collection of Dues)

With respect to the collection of insurance benefits under Article 39 (2), the collection of special disability benefits under Article 78, the collection of special survivors' benefits under Article 79, and the collection of unjust gains under Article 84, Articles 27, 28, 29, 30, 32, 39, 41, and 42 of the Insurance Premium Collection Act shall apply mutatis mutandis. In such cases, the "Health Insurance Corporation" shall be construed as the "Corporation".

Article 86 (Appropriation of Insurance Benefits, etc.)

(1) The Corporation shall be jointly and severally liable pursuant to Article 84 (1) and (3), and the Corporation shall be jointly and severally liable pursuant to Article 84 (2).

insurance benefits, medical or pharmaceutical expenses payable to the insured or industrial accident insurance-related medical institutions

may be appropriated to the amount to be collected under Article 84.

(2) The maximum and procedure of insurance benefits, medical expenses and medicine expenses shall be prescribed by Presidential Decree.

Article 87 (Right to Claim Reimbursement against Third Parties)

(1) Where the NHIS has paid insurance benefits by disaster caused by an act of a third party, it shall limit the amount of such benefits.

The right to claim damages against a third party by a person who has received benefits shall be subrogated: Provided, That this shall not apply to 2 insured persons.

For more than one business owner to divide one business in the same place, and the business owner is among them;

This provision shall not apply in case a disaster occurs due to an act committed by any employee.

(2) In cases falling under paragraph (1), any loss equivalent to insurance benefits under this Act for the same reason from a third person.

Upon receipt of compensation, the Corporation shall limit the amount converted by such amount of compensation in a manner prescribed by Presidential Decree.

No insurance benefits under this Act shall be paid.

(3) If any accident happens due to an act committed by a third person, the beneficiary and policyholder shall report it without delay to the Service.

section 3.

Article 89 (Subrogation of Right to Receive Insurance Benefits)

If the force-based insured (including subcontractors defined in subparagraph 5 of Article 2 of the Insurance Premium Collection Act; hereafter the same shall apply in this Article) has paid in advance money and valuables equivalent to insurance benefits pursuant to the Civil Act or other Acts and subordinate statutes for any occupational accident of his/her employee to the beneficiary for the same reason as the reason for the payment of insurance benefits under this Act, and such money and valuables are deemed to have been paid as a substitute for the insurance benefits, the policyholder shall subrogate the beneficiary's right to receive the insurance benefits

Article 90 (Settlement of Medical Care Benefit Costs)

(1) The NHIS shall be the National Health Insurance Corporation under Article 12 of the National Health Insurance Act or Article 5 of the Medical Care Assistance Act.

The head of a Si/Gun/Gu (hereinafter referred to as "National Health Insurance Corporation, etc.") under Article 42 (1) of this Act shall comply with paragraph (1) of this Article.

(d) Expenses paid preferentially to beneficiaries of medical care benefits under this Act for health insurance and medical care benefits;

(1) If a claim is made, the health insurance and medical care benefits, etc., payable pursuant to this Act;

If it is deemed reasonable, the amount equivalent to the medical care benefits may be paid.

(2) Where the Service has revoked a decision on payment of medical care benefits after paying medical care benefits to a beneficiary.

Health insurance care benefits that may be paid under the National Health Insurance Act or the Medical Care Assistance Act;

If it is deemed that it is suitable for benefits, the Corporation shall pay the amount equivalent to the health insurance benefits.

The Health Insurance Corporation, etc. may request it.

C. former National Health Insurance Act (wholly amended by Act No. 11141 on December 31, 201)

Article 41 (Medical Care Benefits)

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

1. Diagnosis and examination;

2. Supply 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 47 (Claims for and Payment of Medical Care Benefit Costs)

(1) Medical care institutions may claim the Corporation to pay medical care benefit costs. In such cases, the medical care benefit under paragraph (2) shall be paid.

The request for examination on such expenses shall be considered as the claim for medical care benefit costs for the Corporation.

Article 48 (Restriction on Benefits)

(1) If a person entitled to receive insurance benefits falls under any of the following subparagraphs, the Corporation shall not provide the insurance benefits:

(2).

4. Insurance benefits or rewards prescribed by other Acts and subordinate statutes due to occupational or official diseases, injuries or disasters; or

when receiving compensation;

Article 52 (Collection of Unjust Enrichments)

(1) The Service shall receive insurance benefits or medical care benefit costs by deceit or other improper means.

An amount equivalent to the benefits or expenses for benefits shall be collected from the officer in whole or in part.

(3) In the case of paragraph (1), the Corporation shall pay the same household as the person who has received insurance benefits by deceit or other unjust methods.

A policyholder belonging to the insured (if a person who has received insurance benefits by deceit or other unjust methods is a dependent, he shall be such dependent.

Joint and several persons who receive the insurance benefits by deceit or other unjust methods with respect to the employment provided policyholder)

may be required to pay such money due under the same paragraph.

(4) In case of paragraph (1), the medical care institution shall make fraudulent and other improper means from the policyholder or dependent.

When receiving medical care benefit costs, the Corporation shall collect them from the relevant medical care institution, and offer or avoid them.

Payment shall be made without delay to the supporter.

Article 54-3 (Settlement of Medical Care Benefit Costs)

Where the Korea Workers' Compensation and Welfare Service under Article 10 of the Industrial Accident Compensation Insurance Act pays medical care benefits under Article 40 of the Industrial Accident Compensation Insurance Act to a person eligible for medical care benefits under this Act, and the decision for payment thereof is revoked, and the Service claims the expenses for the medical care benefits, it may pay the amount equivalent to the medical care benefits if it is deemed that the medical care benefits are equivalent to the medical care

Article 58 (Right to Indemnity)

(1) If the Service has provided a policyholder or his/her dependent with insurance benefits by an act of a third party, it shall obtain a right to claim compensation for damage to the third party within the limit of expenses incurred in paying such benefits.

(B) If a person who has received an insurance benefit pursuant to paragraph (1) has already received damages from a third party, the Corporation shall not provide insurance benefits to the extent of the amount of such damages.