의료비 할인과 실손의료보험의 보상범위에 관한 연구 - 대법원 2024. 10. 31. 선고 2023다240916 판결을 중심으로 -

Hospitals are offering discounts on hospital fees paid by patients on the grounds of acquaintances or family members of employees. If the patient have indemnity health insurance product to private insurance company, it is in question of whether the insurance company should deduct the discounted medical expenses and pay the insurance money or pay the entire money by insurance policy regardless of the discount amount. The case deals with the dispute between the insured and the insurer as to whether the insurer can deduct the discount when the insurer pays the insured under the actual medical insurance contract if the hospital discounts the patient's medical expenses. From the point of view of the insured, it is considered unfair to deduct it from the insurance company. In this case, the utility value of the indemnity health insurance product will be lowered. However, it is generally known that insurance premiums in indemnity health insurance product are paid based on the actual medical expenses paid by the patient. From this point of view, it is common sense to interpret the phrase ‘the total amount of the insured's expenses’ stated in the Terms and Conditions as ‘the total amount of the insured's actual expenses when the insured receives the medical expenses discount’. Also since the terms of the agreement can not be evaluated as ambiguous, it can not be regarded as contrary to Contra Proferentem Rule. If the insurance company pays the full amount of the insurance without deducting the discounted medical expenses, it will result in unfair advantage to the insured, which is contrary to the principle of the non-life insurance system.