[Case law commentary] Insurer's obligation to explain classification provisions based on primary site
supreme court 2025. 5. 15. sentence 2025all209662 judgment - 1. Classification provisions and explanation obligations based on primary site The most common cancer in Korea is thyroid cancer.(2022by year). Thyroid cancer often metastasizes to other organs or tissues.. insurer(insurance company)If the policyholder develops metastatic thyroid cancer ‘Thyroid cancer diagnosis insurance benefits’Separately from ‘General cancer diagnosis insurance benefits’Among the terms and conditions of the cancer insurance contract to prevent payment of ‘Secondary and unspecified site malignant neoplasms(cancer)In the case of primary malignant neoplasm(cancer)If this is confirmed, the primary site(Area where it first occurred)Classify based on’The contents of the so-called ‘Classification provisions based on primary site’It stipulates. in other words, When thyroid cancer has spread to lymph nodes, Thyroid cancer as primary cancer, Considering lymph node metastatic cancer as a secondary malignant neoplasm, it stipulates that only insurance payments based on the thyroid cancer site will be paid and no insurance payments will be made for lymph node metastatic cancer..However, there has been a long-standing dispute as to whether this classification clause based on the primary site corresponds to an important matter of an insurance contract and is subject to an obligation to explain.. There has been no Supreme Court precedent on this issue until recently., In the lower court cases, there was a tense conflict between cases that said the duty to explain was subject to it and cases that said that it was not the subject..2. In fact, the plaintiff, who is the insurer, and the defendant, who is the policyholder, 2013A cancer insurance contract was signed in 2018..The insurance contract in this case is, Cancer diagnosis fee when cancer diagnosis is confirmed after the coverage start date 300010,000 won paid, When diagnosis of cancer other than minor cancer is confirmed after the coverage start date, cancer diagnosis fee other than minor cancer 4000It is decided to pay 10,000 won.. The special terms and conditions for cancer diagnosis expenses in the insurance contract in this case stipulate classification provisions based on the primary site..The defendant 2023Thyroid cancer in hospital(Corporal code C73), lymph node metastasis(Corporal code C77)After being diagnosed with, I underwent thyroid unilobectomy and central lymph node dissection.. The defendant charged the plaintiff with standard cancer diagnosis fees for thyroid cancer due to lymph node metastasis..But the manuscript ‘Since the classification clause based on the primary site is general and common in transactions and can be expected by the policyholder, it is not subject to the obligation to explain., Plaintiff gave defendant lymph node metastasis(C77)Insurance money according to 7000There is no obligation to pay 10,000 won.’A lawsuit was filed against the defendant to confirm the absence of debt, claiming that.3. my1Judgment system of trial and original trial1planted “① It can be said that classification provisions based on the primary site are generally common in transactions., ② It is reasonable to view the classification clause based on the primary site as a clause that policyholders can fully anticipate, even if there is no separate explanation.. Therefore, the defendant cannot claim a violation of the plaintiff's obligation to explain the classification criteria in this case.”Even if the plaintiff did not fulfill his obligation to explain the classification clause based on the primary site to the defendant, the plaintiff's claim was accepted, saying that the plaintiff's insurance payment obligation to the defendant under the insurance contract in this case does not exist.. The defendant appealed this, but, Centrifugation is also1The defendant's appeal was dismissed, saying that the deliberation's findings of fact and judgment were recognized as fair..4. Supreme Court's Judgment The Supreme Court presented the following two reasons and concluded that the original trial's judgment had an error that influenced the judgment by misunderstanding the legal principles regarding the obligation to explain insurance terms and conditions., The decision was made to overturn the original judgment and remand the case to the original court..go. The classification clause based on the primary site is an important part of the insurance contract.“The classification clause based on the primary site is related to what is to be covered as an insured event in an insurance contract and determines whether there is actually an obligation to pay insurance money., As a core matter of an insurance contract that is directly related to the scope of coverage or insurance payment amount,, It should be considered an important content of the insurance contract in this case because it can directly affect whether or not to conclude an insurance contract or determine the price for it..”me. General insurance policy holders cannot expect that metastatic cancer will not be covered as cancer.“Main contract terms and conditions of the insurance contract in this case ‘asterisk 14’In the classification number ‘C76~C80’of unclear, Secondary and malignant neoplasms of unspecified site’is specified as an independent cancer.. Then, as a general public, without an explanation from the insurer regarding the classification provisions based on the primary site, ‘If you are diagnosed with secondary cancer that has metastasized from thyroid cancer, you cannot receive cancer coverage based on the exclusion clause for thyroid cancer, etc. and the classification clause based on the primary site.’It doesn't seem easy to predict that. In fact, the provisions for classification based on the primary site are so-called thyroid cancer, etc. ‘small cancer’It was introduced in accordance with the insurance terms and conditions improvement plan prepared by the Financial Supervisory Service to resolve the confusion that occurred in insurance payment practices due to the lack of established standards for classifying cases that have spread from one part to another.. Considering the terms and conditions of the insurance contract in this case and the introduction of the classification clause based on the primary site,, Since the classification clause based on the primary site is a general and common matter in transactions, it is difficult to say that the policyholder could have sufficiently anticipated it without a separate explanation..”5. The classification clause based on the primary site of flats results in the fact that cancer patients who have metastasized from a site recognized as a small cancer to a site recognized as a general cancer will have no choice but to receive compensation only for small cancer insurance based on the primary site according to the classification special agreement based on the primary site. ‘Reduction regulations or exemption regulations that limit general cancer insurance payments’corresponds to. According to the classification provisions based on the primary site, in the case of secondary and unspecified malignant neoplasms, as in this case, they are classified based on the thyroid gland, which is the site where the cancer first occurred, and general cancer diagnosis fees cannot be paid., Even if the defendant had been informed of the above special provisions, it cannot be assumed that he would have entered into each insurance contract in this case.. Therefore, the classification clause based on the primary site actually corresponds to the standard for determining whether or not to pay insurance money or the amount, and is an important content of the insurance contract., The classification provisions based on the primary site cannot be viewed simply as confirmation regulations regarding the definition or classification criteria of cancer..In an insurance contract that did not have a classification clause based on the primary site, there was no established standard for classifying cancer that had spread from the thyroid gland to other parts, such as lymph nodes. As confusion arose over whether or not to pay general cancer insurance benefits, the Financial Supervisory Service 2011year 4In the case of metastatic cancer where the menstrual primary site is confirmed, guidelines were issued to improve insurance policy provisions to pay insurance benefits based on the primary cancer., Accordingly, most insurance companies began to include classification provisions based on the primary site in their cancer insurance terms and conditions.. In this way, there have been frequent disputes between policyholders and insurance companies regarding whether cancer that has spread from the thyroid gland to other parts is considered general cancer., In light of the fact that the classification clause based on the primary site reduces the scope of insurance payment by considering metastatic cancer, which could be recognized as general cancer in the absence of a special contract, as primary site cancer., In the case of secondary and unspecified malignant neoplasms, the classification based on the primary site and exclusion from general cancer cannot be said to be a matter that the policyholder was aware of at the time of entering into the insurance contract in this case, or a matter that was common and common in transactions and could have been fully expected even without separate explanation, or a matter that is merely an amplification of the standard of medical judgment.. Rather, there has been a lot of confusion regarding the classification method for metastatic cancer., It should be seen that the need to explain the contents in detail was more urgent in order to avoid a situation where the policyholder enters into an insurance contract without knowing this and suffers an unexpected disadvantage..In addition, the classification provisions based on the primary site include technical terms, etc., so the content is not simple., Even though malignant neoplasms exist in the thyroid gland and other parts of the body other than the thyroid gland, it is difficult to understand without further explanation that it is treated only as thyroid cancer.. In particular, if the meaning of the terms and conditions is unclear, such as because the insurance contract provisions can be interpreted multiple times and each interpretation is reasonable, they must be interpreted in a way that is favorable to the customer.(supreme court 2008all81633 See Judgment).Considering the above, it is reasonable that the target judgment determined that the classification clause based on the primary site is an important content of the insurance contract and is subject to the obligation to explain..Until recently, there was no Supreme Court precedent on whether the classification clause based on the primary site was subject to the obligation to explain, and the judgments of the lower courts were mixed., The Supreme Court 2025year 3month 13Day 2023all250746 Starting with the ruling 2022all263813, 2023all273633, 2023all245058 Judgment and target judge 2025all209662 By issuing rulings, etc., it was made clear that the classification provisions based on the primary site are subject to the obligation to explain..The ruling is considered to be of great significance in that it presents unified standards for statutory interpretation related to the above issues.. In addition, it is expected that the ruling will significantly reduce disputes over whether the classification clause based on the primary site is subject to the obligation to explain in the future.. [View full article]
[Case law commentary] Insurer's obligation to explain classification provisions based on primary site (link)