[Plaintiff, Appellant] Plaintiff, Litigation Representative Attorneys Woo Deok-seong and 1 other
[Defendant, Appellee] Korea Workers' Compensation and Welfare Service (근로복지공단)
[Lower Court Judgment] Seoul High Court, Judgment of September 9, 1994, Case No. 93Gu29756
[Order]
The judgment of the court below is reversed and the case is remanded to the Seoul High Court.
[Reasoning]
We examine the grounds of appeal.
1. The court below, based on the evidence cited therein, found the following facts: On November 21, 1979, while the Plaintiff was working as an employee of Non-party ○○○○ Construction Co., Ltd., he suffered a fall accident and sustained injuries consisting of (1) an open fracture of the left parietal-occipital bone, (2) an acute epidural and subdural hematoma on the left side, and (3) cerebral contusion; that he received medical care pursuant to the Industrial Accident Compensation Insurance Act (산업재해보상보험법); that upon the initial conclusion of medical care on March 31, 1985, it was determined that he had residual sequelae of severe cerebral contusion, including spastic quadriplegia, speech and memory impairment, aphasia, and severe dizziness, and that no particular improvement was expected in the future with respect to the gait disturbance caused by spastic quadriplegia, the speech impairment, dizziness, and emotional instability caused by the cerebral contusion; that after receiving the treatment termination measure, he was determined to be a person with significant impairment of nervous system function who was unable to engage in labor for the rest of his life, and accordingly was granted a disability grade of Grade 3, Item 3 under Article 9-5 of the Industrial Accident Compensation Insurance Act; that even after the aforementioned conclusion of treatment, the Plaintiff continued to receive outpatient treatment from time to time at □□□□ General Hospital located in △△ City, and on August 29, 1989, was determined by that hospital to have a Grade 2 mental/physical disability; that from February 25, 1991 to May 18 of the same year, he was hospitalized and treated at the Department of Neurosurgery of ☆☆☆☆ Hospital located in ◇◇-dong, Yeongdeungpo-gu, Seoul, and was then discharged; that from May 24, 1991 to January 9, 1992, he was re-admitted to and treated at the same hospital and then discharged; that from February 4, 1993 to September 16 of the same year, he received outpatient treatment at the same hospital; and that on October 5 of the same year, he was again admitted to the same hospital and continued to receive treatment until around June 13, 1994.
The court below further found that on November 6, 1992, the Plaintiff applied to the Defendant for re-treatment (재요양) with respect to (1) cerebral contusion, (2) open skull fracture, (3) acute subdural hematoma, and (4) hydrocephalus; that on December 23 of the same year, the Defendant issued the disposition at issue in this case disapproving re-treatment, on the ground that the Plaintiff's symptoms had not become significantly aggravated compared to his condition at the time of the conclusion of treatment or at the time disability benefits were paid, such that the necessity for active treatment was not recognized, and that no medical opinion recognized that a therapeutic effect could be expected from re-treatment; that Non-party, a specialist in neurosurgery at the aforementioned ☆☆☆☆ Hospital who had treated the Plaintiff as described above, prepared a medical opinion dated September 22, 1992 stating that "the Plaintiff is a patient whose treatment was concluded after undergoing a craniotomy and ventriculo-peritoneal shunt surgery for the injuries sustained at the time of the accident, and receiving inpatient and outpatient care; that gait disturbance due to quadriplegia (a condition requiring the accompaniment of a caregiver) and mental impairment currently persist continuously; that administration of anticonvulsants for the next three months is deemed necessary; and that a subsequent re-evaluation is required"; that, meanwhile, the Defendant's advisory physician expressed an opinion to the effect that, even if the treatment set forth in the above opinion were administered, no improvement in symptoms would be expected; and that the said Non-party, in his reply to this Court's inquiry into the facts, stated that the Plaintiff's current symptoms—namely, speech impairment, dizziness, spastic quadriplegic gait disturbance, impairment of judgment and mental capacity, and difficulty urinating—had worsened compared to the time of conclusion of treatment and required care, that at present only minor improvement could be expected but no significant therapeutic effect beyond the current condition could be expected, that symptomatic treatment methods such as administration of anticonvulsants, physical therapy, and administration of cerebral metabolism enhancers were available for the Plaintiff, but that even with such treatment, any particular expected effect beyond the present condition would likely be scant, and that even with active treatment, it was thought that only maintenance of the present condition would be possible. The court below also found that the Plaintiff was born on (date of birth omitted) and was a male aged ∇∇ years and 9-odd months at the time of the aforementioned conclusion of treatment.
Based on these findings, the court below held as follows: As shown in the above findings, the Plaintiff's treatment was concluded on March 31, 1985 on the ground that his symptoms had stabilized, and he was accordingly granted a disability grade and paid disability benefits; the residual symptoms at the time of that conclusion of treatment and the current symptoms cited by the Plaintiff in filing the present application for re-treatment are nearly identical except for the difficulty in urination; the symptom of difficulty in urination is also considered to be one of the symptoms naturally arising from spastic quadriplegia; even with active treatment for these symptoms, only minor improvement could be expected, with no significant therapeutic effect beyond the current condition; and in light of the period from the conclusion of treatment to the filing of the present application for re-treatment, as well as the Plaintiff's age, it is considered that the Plaintiff's current symptoms represent merely a natural increase, due to the passage of time, in the degree of the gait disturbance caused by spastic quadriplegia, the speech and memory impairment caused by the cerebral contusion, dizziness, and emotional instability that remained at the time of the conclusion of treatment, and do not constitute a medical condition in which the symptoms have become significantly aggravated compared to the condition at the time of conclusion of treatment such that the necessity for active medical care is recognized. The court below further held that the mere circumstance that the Plaintiff currently cannot even perform ordinary physiological activities without the assistance of a caregiver is insufficient to establish the necessity of re-treatment for the Plaintiff, and that there is no other evidence to establish such necessity; accordingly, the court below held that the Defendant's disposition disapproving re-treatment for the Plaintiff was lawful.
2. However, neither the Industrial Accident Compensation Insurance Act nor its Enforcement Decree, as in effect at the time of the disposition at issue, contained any provision concerning the requirements for re-treatment. Although the Regulations on the Handling of Medical Care Management and Medical Care Benefit Affairs (요양관리및요양급여업무처리규정), a Ministry of Labor directive, contain provisions concerning this matter, these regulations have no basis in the Industrial Accident Compensation Insurance Act or its Enforcement Decree, and, given their nature and content, merely establish internal administrative guidelines for the handling of medical care management and medical care affairs under the Industrial Accident Compensation Insurance Act; they have no binding effect externally upon the courts or the general public. Accordingly, the legality of the disposition disapproving re-treatment at issue in this case must be judged according to whether it conforms to the purport of Article 9-3 of the former Industrial Accident Compensation Insurance Act (before its full amendment by Act No. 4826 of December 22, 1994). Re-treatment differs in nature from initial medical care only in that it is care provided, after medical care has once been concluded, for a recurrence of the relevant injury or illness, or for complications arising from the relevant injury or illness; in all other respects it is not different in nature from initial medical care. Accordingly, the requirements for re-treatment are no different from the requirements for medical care generally, except for the point that re-treatment is care administered after the conclusion of medical care.
Therefore, in addition to the requirements for medical care, the requirements for re-treatment are satisfied where it is recognized that there is a medically substantial causal relationship between the originally injured or diseased condition and the condition for which re-treatment is applied, and where there is a medical opinion that, compared to the condition at the time of conclusion of treatment of the original injury or illness or at the time disability benefits were paid, the symptoms have worsened such that a therapeutic effect can be expected from re-treatment; it is not the case that re-treatment should be recognized only where the symptoms have become significantly aggravated, compared to the condition at the time of conclusion of treatment of the original injury or illness or at the time disability benefits were paid, such that the necessity for active treatment is recognized.
In the present case, as to the requirement, among the above requirements for re-treatment, that there be a medically substantial causal relationship between the original injury or illness and the recurred disease, this is sufficiently established by the factual findings made by the court below. Furthermore, according to the result of the lower court's inquiry into the facts addressed to the director of ☆☆☆☆ Hospital, the Plaintiff's current symptoms have worsened compared to the condition at the time of conclusion of treatment of the original injury or illness or at the time disability benefits were paid, such that care is required, and although no significant therapeutic effect beyond the present condition can be expected from treatment, minor improvement can be expected. This leaves room to find that a medical therapeutic effect could be expected from re-treatment. Nevertheless, the court below, having found that the Plaintiff's current symptoms do not constitute a condition in which the symptoms have become significantly aggravated compared to the condition at the time of conclusion of treatment such that the necessity for active medical care is recognized, dismissed the Plaintiff's claim in this case; in so doing, the court below failed to exhaust the necessary examination and erred in its understanding of the legal principles concerning the requirements for re-treatment. The argument pointing this out is well-founded.
3. Accordingly, the judgment of the court below is reversed and the case is remanded, and this Judgment is rendered as set forth in the Order, by the unanimous opinion of the Justices participating in the decision.
Justice Lee Yong-hoon (Presiding Justice), Park Man-ho, Park Jun-seo (Justice in Charge), Kim Hyung-seon