〈Case in which, after the Health Insurance Review and Assessment Service adjusted its previous review results on automobile insurance medical fees, an insurance company accordingly sought from a person operating a medical institution the return of part of the automobile insurance medical fees it had already paid〉

【Holding】

[1] Where the effect of deemed agreement has not arisen with respect to the Health Insurance Review and Assessment Service's review results on automobile insurance medical fees under Articles 12-2, 19, and 21 of the former Guarantee of Automobile Accident Compensation Act and other provisions, whether the Health Insurance Review and Assessment Service may adjust its previous review results ex officio (affirmative)

[2] The meaning of ‘the period under paragraph (1) from the date of receipt of notice of the Health Insurance Review and Assessment Service's review results on automobile insurance medical fees,’ the point at which the deemed agreement under Article 19(3) of the former Guarantee of Automobile Accident Compensation Act is established (= 90 days as prescribed in Article 6-4(1) of the former Enforcement Rule of the Guarantee of Automobile Accident Compensation Act), and whether deemed agreement is not established during the objection period (affirmative) / The point at which an agreement may be regarded as having been established because neither the insurance company nor the medical institution objected to the Health Insurance Review and Assessment Service's review results on automobile insurance medical fees (= when the 90-day objection period has elapsed without the insurance company or the medical institution having objected to the review results and without the Health Insurance Review and Assessment Service having made a review decision adjusting the previous review results)

【Summary of Decision】

[1] Article 12-2(1) of the former Guarantee of Automobile Accident Compensation Act (before amended by Act No. 19981 on January 9, 2024; hereinafter the ‘former Automobile Compensation Act’) provides that “an insurance company, etc. may entrust the review and adjustment of automobile insurance medical fees claimed by a medical institution under Article 12(4) and related affairs to a specialized review agency prescribed by Presidential Decree,” and paragraph (4) provides that “where such affairs are entrusted to a specialized review agency under paragraph (1), the methods and procedures for claims, review, objections, and the like shall be prescribed by Ordinance of the Ministry of Land, Infrastructure and Transport.”

Article 11-2 of the Enforcement Decree of the Guarantee of Automobile Accident Compensation Act designates the Health Insurance Review and Assessment Service (hereinafter the ‘Review and Assessment Service’) as the specialized review agency in charge of the review and adjustment of automobile insurance medical fees and related affairs; Article 6-3 of the former Enforcement Rule of the Guarantee of Automobile Accident Compensation Act (before amended by Ordinance of the Ministry of Land, Infrastructure and Transport No. 1358 on July 10, 2024) prescribes the methods and procedures for the Review and Assessment Service's review of automobile insurance medical fees; and Article 6-5 thereof provides that detailed matters necessary for the review and the like shall be determined by the Minister of Land, Infrastructure and Transport.

Pursuant to that delegation, Article 23(7) of the former Regulations on the Handling of Review Affairs for Automobile Insurance Medical Fees (before amended by Ministry of Land, Infrastructure and Transport Notice No. 2024-830 on December 23, 2024) provides, in effect, that ‘where the President of the Review and Assessment Service deems it necessary to verify the details of the review of automobile insurance medical fees, the Review and Assessment Service may verify and adjust the review details after payment of the automobile insurance medical fees.’

In light of the content of the above provisions, the Review and Assessment Service must review and adjust whether automobile insurance medical fees are appropriate, and the scope of the affairs entrusted to the Review and Assessment Service includes not only reviewing the automobile insurance medical fees claimed by medical institutions but also adjusting its previous review results. Accordingly, it is reasonable to hold that, so long as the effect of deemed agreement has not arisen with respect to the Review and Assessment Service's review results under Articles 12-2, 19, and 21 of the former Automobile Compensation Act and other provisions, the Review and Assessment Service may adjust its previous review results ex officio.

[2] Articles 12-2, 19, and 21 of the former Guarantee of Automobile Accident Compensation Act (before amended by Act No. 19981 on January 9, 2024; hereinafter the ‘former Automobile Compensation Act’) and other provisions provide that, where neither the insurance company nor the medical institution objects to the review results of the Health Insurance Review and Assessment Service (hereinafter the ‘Review and Assessment Service’), the specialized review agency, on a medical institution's claim for payment, or to the review decision of the Automobile Insurance Medical Fee Dispute Deliberation Committee, and the like, an agreement to that effect is deemed to have been established between the insurance company and the medical institution. Specifically, Article 19(1) of the former Automobile Compensation Act provides that “where an insurance company, etc. or a medical institution objects to the review results under Article 12-2(2), it may request a review by the Automobile Insurance Medical Fee Dispute Deliberation Committee within 30 days from the date of receipt of notice of the results of the objection,” and paragraph (3) provides that “an insurance company, etc. or a medical institution that has been notified of the review results of the specialized review agency under Article 12-2(1) shall, if it does not request a review within the period under paragraph (1), be deemed to have agreed to the contents claimed for payment by the medical institution or to the review results on the last day of that period.”

However, Article 12-2(4) of the former Automobile Compensation Act provides that the methods and procedures for claims to, review by, and objections to the Review and Assessment Service and the like shall be prescribed by Ordinance of the Ministry of Land, Infrastructure and Transport, and Article 6-4(1) of the former Enforcement Rule of the Guarantee of Automobile Accident Compensation Act (before amended by Ordinance of the Ministry of Land, Infrastructure and Transport No. 1358 on July 10, 2024; hereinafter the ‘former Enforcement Rule of the Automobile Compensation Act’), enacted under that delegation, provides that “where a medical institution or an insurance company, etc. objects to the review results of the Review and Assessment Service under Article 6-3(3), it may file an objection with the Review and Assessment Service within 90 days from the date of receipt of notice of the review results.” This is intended to guarantee medical institutions and insurance companies, etc. an opportunity to object and to promote the appropriate calculation of automobile insurance medical fees; therefore, absent special circumstances, the above 90-day objection period must be fully guaranteed.

‘The period under paragraph (1) from the date of receipt of notice of the Review and Assessment Service's review results,’ the point at which the deemed agreement provided for in Article 19(3) of the former Automobile Compensation Act is established, must be construed not as the 30 days prescribed in paragraph (1) as the period within which a review may be requested from the Deliberation Committee, but as the 90 days prescribed in Article 6-4(1) of the former Enforcement Rule of the Automobile Compensation Act as the period within which an objection may be raised to the Review and Assessment Service's review results, and deemed agreement must be regarded as not being established during such objection period.

Consequently, for an agreement to be regarded as having been established because neither the insurance company nor the medical institution objected to the Review and Assessment Service's review results, the 90-day objection period must have elapsed without the insurance company or the medical institution having objected to the review results and without the Review and Assessment Service having made a review decision adjusting the previous review results.

【Referenced Statutes】

[1] Articles 12-2, 19, and 21 of the former Guarantee of Automobile Accident Compensation Act (before amended by Act No. 19981 on January 9, 2024), Article 11-2 of the Enforcement Decree of the Guarantee of Automobile Accident Compensation Act, Articles 6-3 and 6-5 of the former Enforcement Rule of the Guarantee of Automobile Accident Compensation Act (before amended by Ordinance of the Ministry of Land, Infrastructure and Transport No. 1358 on July 10, 2024), Article 23(7) of the former Regulations on the Handling of Review Affairs for Automobile Insurance Medical Fees (before amended by Ministry of Land, Infrastructure and Transport Notice No. 2024-830 on December 23, 2024) [2] Articles 12-2, 19, and 21 of the former Guarantee of Automobile Accident Compensation Act (before amended by Act No. 19981 on January 9, 2024), Article 11-2 of the Enforcement Decree of the Guarantee of Automobile Accident Compensation Act, Article 6-3(3) and Article 6-4(1) of the former Enforcement Rule of the Guarantee of Automobile Accident Compensation Act (before amended by Ordinance of the Ministry of Land, Infrastructure and Transport No. 1358 on July 10, 2024)


(Source : Supreme Court Decision 2024Da310102, March 13, 2025 | Judicial Information Disclosure Portal, Precedents)