보험약관상 ‘수술 해당성 및 수술 횟수’ 판단에 관한 연구 - 서울고등법원 2024.2.1. 선고 2023나2009403 판결을 중심으로 -

With the development of medical technology, treatment methods have become very diverse, and such advancements in medical technology, such as replacing surgical treatment with drug treatment or replacing open surgery with endoscopic surgery, have led to healthier lives. However, due to the nature of insurance as a product that is maintained for the longest period of time among financial products, there are limitations in reflecting all developments in medical technology in advance and listing them as collateral in the insurance terms and conditions. In relation to surgery, there are frequent disputes over whether the surgery is covered under insurance terms and conditions. As medicine continues to develop, related disputes are bound to continue in the future due to the development of medical technology and medical equipment. In relation to this, the Seoul High Court recently held a lawsuit claiming insurance money after a total of 115 cryocoagulation surgeries were performed under the diagnosis of 'corns and warts', and it was judged that it met the definition of surgery under the insurance terms and conditions, and the ruling was that all insurance payments were justified. there was. Insurance contracts that were developed and sold in a medical environment where most of the existing surgical and invasive surgeries were performed were intended to cover surgical insurance premiums, and paid surgical insurance premiums to cover the risks associated with treatment or when the treatment prognosis was worse than that of general treatment. However, as medical technology develops, one may wonder whether non-invasive surgery can be covered in the same way as existing surgery coverage. In other words, in the case of new medical technology, it is less invasive than existing surgical procedures, but in many cases, repeated procedures must be performed several times to replace the effect of existing surgical procedures. If all of these must be recognized as the number of surgeries, the number of surgeries at the time of insurance product development Contrary to the intention, problems with excessive insurance payment may arise. In particular, the fact that a total of KRW 115,277,089 was claimed for 115 cryocoagulation surgeries in the target judgment was made the subject of a review of the judgment because it is difficult to accept that it is general surgery insurance money. In the case of non-invasive surgery being replaced by new medical technology, we would like to present a reasonable method for determining whether it is eligible for surgery and the criteria for determining the number of surgeries. As a result of the study, the following conclusions were drawn regarding interpretation issues when applying surgery terms and conditions to existing insurance products and ways to improve insurance terms and conditions in the future. First, surgeries based on new medical technologies will be covered by insurance, but must be judged individually depending on whether they replace existing surgeries. Second, it is necessary to define the definition of surgery by linking the form of coverage of surgery insurance money with items such as surgery and treatment in the nursing care benefits of the National Health Insurance Act. Third, with regard to the number of surgical insurance payments, if it is a repeat procedure for one disease or if it is a replacement for existing surgery, it is necessary to limit the number of surgeries. It is thought that it is appropriate to apply general medical opinion to ensure objectivity, rather than being limited to the attending physician.