보험사고 발생 후 고지의무 위반에 따른 보험계약해지 및 보험금 지급책임의 범위

An issue arises when considering the case where an insurance accident has occurred before the termination of the accident insurance contract (“Insurance Contract”) and certain losses under the terms and conditions are covered (“Covered Losses”) whereas other losses are not covered based on a failure to disclose a material fact when applying for the concerned insurance (“Non-Covered Losses”) and those losses that arise after the termination of the Insurance Contract in relation to the covered losses (“Post-Termination Losses”) which should be covered in the same manner as Covered Losses arising during the term of the insurance contract. In this case, the issue should be reviewed and determined based on the continuity or unity of the underlying facts for the Covered Losses, Non-Covered Losses and Post-Termination Losses. Generally, the preliminary diagnosis of cancer, admission to a medical facility surgery and the subsequent death may all be viewed as a single accident (or occurrence) all arising from the development of cancer in an individual patient (each a “Cancer-Related Event”). However, each of these Cancer-Related Events constitute a single occurrence of a particular risk all in sequence when calculating insurance premiums and payment of claims from an insurance perspective. From an underwriting and actuarial perspective, insurance premiums are calculated by the insurer and paid by the policyholder for each event arising from the initial diagnosis cancer. Therefore, it is also reasonable to view each Cancer-Related Event as an independent insurance accident resulting from the occurrence following the diagnosis of cancer. Based on the foregoing, if the Insurance Contract is terminated by the insurer based on a contractual grounds for termination after the diagnosis of cancer in an individual patient (i.e., a single Cancer-Related Event) and a subsequent death by cancer occurred, then the death as a Cancer-Related Event should be regarded as a new insurance accident separate and apart from all other Cancer-Related Events. In this case and in principle, the insurer would not be responsible and liable for any Post-Termination Losses breaking the chain of Cancer-Related Losses due to each being a single accident covered under the Insurance Contract. Notwithstanding, it is highly unlikely that an insurer would arbitrarily exercise a termination right under the Insurance Contract for failing to disclose a material fact by the policyholder to the insurer for underwriting and actuarial purposes. Moreover, a distinction should be made between those Post-Termination Losses related to the basis for the termination of the Insurance Contract and those deemed as Uncovered Losses unrelated to the same termination of the Insurance Contract. In the event that an insurer declines to pay claims made by a policyholder, insured or beneficiary on the basis that a Cancer-Related Loss is an Uncovered Loss because it is a Post-Termination Loss following the termination of an Insurance Contract may be subject to a dispute as well as public criticism from a consumer/customer protection perspective. In this respect, it can be said that the majority view and relevant preceddents have had some favorable impact on issue of coverage and liability of Post-Termination Losses; but examination and discussion with legal and regulatory reform must be conducted to arrive at reasonable interpretations and compensation for insurance accidents which are and should be covered but are unrelated to those claims due to the breach of a policyholder’s duty to disclose material facts when entering into an Insurance Contract.