실손 의료보험 보상한도 원상회복 조정결정 고찰- 소비자분쟁조정위원회 조정결정문을 중심으로 - (A Study on the adjustment decision of restitution in the indemnity limit of medical indemnity insurance)

서지정보

· 발행기관 : 한국금융법학회
· 수록지 정보 : 금융법연구 / 10권 / 2호 / 169 ~ 198페이지
· 저자명 : 김창호

초록

On October 31st, 2013, six insurance companies including HyundaiMarine & Fire Insurance, LIG Insurance, Meritz Marine & Fire Insurance, HanwhaGeneral Insurance, Heungkuk Fire & Marine Insurance and MG Non-LifeInsurance officially rejected the decision made by Korea Consumer Agency'sConsumer Dispute Settlement Commission on September 25th, 2013 that "healthinsurance's indemnity limit should be restored from the reduced amount of 50million Korean won to the original amount, 100 million." When either partyrejects the determination within 15 days since the decision is made, themeditation loses its legal effects and the applicant can take the case to the court.
That is, the insurance companies' unilateral reduction of health insurance'sindemnity limit will be treated in the court.
Regarding the issue, the Consumer Dispute Settlement Commissionwrote this article in order to look at the decision of restoring the indemnity limitto the original state from diverse perspectives. First, we reviewed that it is hardto say that the insurers fulfill the obligation of indication and explanation thatthe limit of indemnity would decrease from 100 million to 50 million toinsurance policy holders under the Commercial Law and the Contract Terms Regulation Act. Second, the additional rules of the Regulation on Supervision ofInsurance Business, the Enforcement Procedures on Supervision of InsuranceBusiness and Supervision Regulation are applied only to the share of cost, butnot to reduction of indemnity limit. The Enforcement Procedure does not havelapse provision unlike the additional rules of the Regulation on Supervision,therefore, insurers who reduced the limit based on the above-mentionedregulations are considered to misinterpret the regulations. Lastly, the FinancialService Commission which is in charge of defective administrative activitiesshould revoke the administrative activities with flaws to save subscribers. Inaddition, the Financial Service Commission should issue a new order ofadministrative activity to raise the indemnity limit from 50 million to 100 millionKorean won according to the Clause 4 of the Article 131 of the InsuranceBusiness Act. If insurers explained about the reduction in indemnity limit andthe subscribers are aware of the fact, the reduction of the limit would becomean important standard for subscribers to determine whether they subscribe theinsurance policy. And if they know the fact, it is highly likely that people donot buy the insurance policy. All what mentioned above explains that insurersdid not give an explanation about the fact. And it is fair to say that themarketing strategy which encourages consumers to buy the insurance policybefore the policy goes out of market would not be possible and insurers couldnot get 600,000 people subscribed to the insurance policy within a short periodof 2 months if subscribers know the fact. In addition, insurers send anotification letter about the reduction in indemnity limit when the insurancepolicy is renewed and did not fulfill the obligation of explanation faithfully.
Therefore, under the Korean Policy Regulation Act, the reduction should not beconsidered as part of the renewed insurance policy or should not be included inthe policy, but the insurance policy is renewed with the original insuranceterms. Therefore, we determine that it was the right decision we have made inthe meditation that the indemnity limit of health insurance signed on August28th, 2009 between insurer and subscriber should stay at 100,000,000 won.

영어초록

On October 31st, 2013, six insurance companies including HyundaiMarine & Fire Insurance, LIG Insurance, Meritz Marine & Fire Insurance, HanwhaGeneral Insurance, Heungkuk Fire & Marine Insurance and MG Non-LifeInsurance officially rejected the decision made by Korea Consumer Agency'sConsumer Dispute Settlement Commission on September 25th, 2013 that "healthinsurance's indemnity limit should be restored from the reduced amount of 50million Korean won to the original amount, 100 million." When either partyrejects the determination within 15 days since the decision is made, themeditation loses its legal effects and the applicant can take the case to the court.
That is, the insurance companies' unilateral reduction of health insurance'sindemnity limit will be treated in the court.
Regarding the issue, the Consumer Dispute Settlement Commissionwrote this article in order to look at the decision of restoring the indemnity limitto the original state from diverse perspectives. First, we reviewed that it is hardto say that the insurers fulfill the obligation of indication and explanation thatthe limit of indemnity would decrease from 100 million to 50 million toinsurance policy holders under the Commercial Law and the Contract Terms Regulation Act. Second, the additional rules of the Regulation on Supervision ofInsurance Business, the Enforcement Procedures on Supervision of InsuranceBusiness and Supervision Regulation are applied only to the share of cost, butnot to reduction of indemnity limit. The Enforcement Procedure does not havelapse provision unlike the additional rules of the Regulation on Supervision,therefore, insurers who reduced the limit based on the above-mentionedregulations are considered to misinterpret the regulations. Lastly, the FinancialService Commission which is in charge of defective administrative activitiesshould revoke the administrative activities with flaws to save subscribers. Inaddition, the Financial Service Commission should issue a new order ofadministrative activity to raise the indemnity limit from 50 million to 100 millionKorean won according to the Clause 4 of the Article 131 of the InsuranceBusiness Act. If insurers explained about the reduction in indemnity limit andthe subscribers are aware of the fact, the reduction of the limit would becomean important standard for subscribers to determine whether they subscribe theinsurance policy. And if they know the fact, it is highly likely that people donot buy the insurance policy. All what mentioned above explains that insurersdid not give an explanation about the fact. And it is fair to say that themarketing strategy which encourages consumers to buy the insurance policybefore the policy goes out of market would not be possible and insurers couldnot get 600,000 people subscribed to the insurance policy within a short periodof 2 months if subscribers know the fact. In addition, insurers send anotification letter about the reduction in indemnity limit when the insurancepolicy is renewed and did not fulfill the obligation of explanation faithfully.
Therefore, under the Korean Policy Regulation Act, the reduction should not beconsidered as part of the renewed insurance policy or should not be included inthe policy, but the insurance policy is renewed with the original insuranceterms. Therefore, we determine that it was the right decision we have made inthe meditation that the indemnity limit of health insurance signed on August28th, 2009 between insurer and subscriber should stay at 100,000,000 won.

참고자료

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