[Plaintiff, Appellant] Plaintiff, litigation successor of the deceased Nonparty (Attorney Kim Eun-cheol of Peace Law Firm, for the Plaintiff)
[Defendant, Appellee] Korea Workers' Compensation & Welfare Service
[Lower Court Judgment] Seoul High Court Decision 2019Nu47973, decided December 20, 2019
[Order]
The lower court judgment is reversed, and the case is remanded to the Seoul High Court.
[Reasoning]
The grounds of appeal are examined.
1. Overview of the case and issue
A. According to the reasoning of the lower court judgment and the record, the following facts may be found.
(1) Around July 22, 2005, while working at "○○○○○ Gas Station" located in Jungwon-gu, Seongnam-si, the Nonparty suffered an accident (hereinafter "the instant accident") in which his right eye was exposed to caustic soda used for car washing, and was diagnosed with "chemical burn of the right corneal" (hereinafter "the preceding injury/disease"). Around that time, he received approval for occupational medical care from the Defendant and received outpatient treatment (hereinafter "the preceding medical care") from July 22, 2005 to September 30, 2005.
(2) On February 2, 2018, the Nonparty was diagnosed at △△△△△△△ Hospital with "visual impairment (right eye, light perception only) caused by chemical burn of the right cornea, endophthalmitis of the right eye, and retinal detachment of the right eye" (hereinafter collectively "the instant disability"), and on March 2, 2018, filed a claim for disability benefits with the Defendant.
(3) On March 8, 2018, the Defendant issued a decision not to pay disability benefits to the Nonparty on the ground that "the preceding injury/disease was cured on September 30, 2005, the date the preceding medical care ended, and the right to claim disability benefits was extinguished after the three-year extinctive prescription period set forth in Article 112(1)(1) of the former Industrial Accident Compensation Insurance Act (산업재해보상보험법) (before amendment by Act No. 15665 of June 12, 2018; hereinafter "the former Industrial Accident Insurance Act") had elapsed."
(4) The Nonparty died on September 20, 2018, while the first instance trial was pending, and the Plaintiff, his spouse, succeeded to the litigation proceedings.
B. The issue in this case is whether, as of the date the Nonparty filed the claim for disability benefits, the right to claim disability benefits regarding the instant disability had been extinguished by the completion of the extinctive prescription period.
2. Judgment of the lower court
The lower court determined, for the reasons set forth below, that the preceding injury/disease could be deemed to have been cured on September 30, 2005, and that the extinctive prescription period for the right to claim disability benefits regarding the preceding injury/disease ran from the day following the date of cure; since the Nonparty did not file the claim for disability benefits regarding the instant disability with the Defendant until March 2, 2018, after the three-year extinctive prescription period had elapsed from that date, the Nonparty's right to claim disability benefits was extinguished by completion of the extinctive prescription period.
A. According to the results of the medical record appraisal commissioned by the first instance court, the medical record appraiser opined that it was reasonable to view September 30, 2005 as the date treatment for the preceding injury/disease was completed, and presented a medical opinion to the effect that it was difficult to recognize a direct causal relationship between the instant accident or the preceding injury/disease and the "right eye cataract diagnosed on September 19, 2006, endophthalmitis of the right eye diagnosed on September 14, 2011, and vitreous hemorrhage and retinal detachment of the right eye diagnosed on November 14, 2017"; no special circumstances were found that would render this opinion unreasonable.
B. Considering that various surgeries, including right eye cataract surgery and right eye vitrectomy, were performed between July 22, 2005, the date of the instant accident, and February 7, 2017, and that the deceased had an underlying disease, diabetes, it is also difficult to view the full-thickness corneal re-transplantation surgery performed on the Nonparty's right eye on February 7, 2017 as a recurrence of the preceding injury/disease.
3. Judgment of the Supreme Court
A. (1) Under the former Industrial Accident Insurance Act, the right to receive insurance benefits is extinguished by completion of the extinctive prescription period if not exercised for three years (Article 112(1)(1)), and the extinctive prescription period runs from the time the right may be exercised (Article 112(2), Article 166(1) of the Civil Act (민법)). Where a worker, even after receiving medical care benefits and being cured, still has a disability in the body, etc., disability benefits shall be paid (Article 57(1)). Here, "cure" means that an injury or disease has fully healed, or that no further therapeutic effect can be expected and the symptoms have reached a fixed state (Article 5(4)). Accordingly, under the former Industrial Accident Insurance Act, the extinctive prescription period for the right to claim disability benefits runs from the time the cause for payment of disability benefits arises, i.e., the time of cure (see Supreme Court Decision 97Nu6544, decided August 22, 1997, etc.).
(2) Under the former Industrial Accident Insurance Act, where the occupational injury or disease that was the subject of medical care recurs, or the condition worsens compared to the state at the time of cure, after the worker has received medical care benefits and been cured, and active treatment is necessary to cure such recurrence or worsened condition, the worker may receive re-treatment medical care (Article 57(1)). Re-treatment medical care is of the same nature as the initial medical care, except that it is medical care provided, after the initial medical care has been concluded, for a recurrence of the preceding injury/disease or for complications arising from the preceding injury/disease. Accordingly, the requirements for re-treatment medical care are satisfied, in addition to the general requirements for medical care, if there is a recognized proximate causal relationship between the preceding injury/disease and the injury/disease for which re-treatment medical care is sought, and there is a medical opinion that the symptoms have worsened compared to the state at the time the preceding medical care was concluded, such that a therapeutic effect can be expected from re-treatment medical care. It is not necessary that the preceding injury/disease be the direct cause of the injury/disease for which re-treatment medical care is sought, nor is it necessary that the symptoms have markedly worsened compared to the state at the time treatment of the original injury/disease was concluded such that the necessity for active treatment is recognized (see Supreme Court Decision 2002Du1762, decided April 26, 2002).
(3) Under the former Industrial Accident Insurance Act, where, after receiving re-treatment medical care and being cured, the disability condition has worsened compared to before, disability benefits are paid according to the disability grade corresponding to the worsened disability condition, and the method of calculating and paying disability benefits following re-treatment medical care is prescribed by Presidential Decree (Article 60(2)). Article 58 of the Enforcement Decree of the Industrial Accident Compensation Insurance Act (산업재해보상보험법 시행령), enacted pursuant to this delegation, classifies recipients of disability benefits into those who received a disability compensation pension and those who received a disability compensation lump-sum payment, and further divides the calculation and payment method according to whether the recipient claims disability benefits following re-treatment medical care as a disability compensation pension or as a disability compensation lump-sum payment. It provides that where a person who received a disability compensation lump-sum payment claims a disability compensation pension because the disability condition following re-treatment medical care has worsened compared to before, "the disability compensation pension corresponding to the changed disability grade shall be paid from the month following the month in which the date of cure following re-treatment medical care falls, but the disability compensation pension shall not be paid for a period equivalent to the number of days for which the disability compensation lump-sum payment already paid was calculated" (Paragraph 3, Item 1; hereinafter "the instant provision").
The purpose of the instant provision is to prevent the unreasonable result whereby a person who received medical care benefits and a disability compensation lump-sum payment due to an occupational accident, and whose disability condition worsens after re-treatment medical care such that he or she would receive the full disability compensation pension corresponding to the changed disability grade, would end up receiving duplicate compensation for the portion of disability benefits already compensated. Accordingly, where a person who suffered a bodily disability due to an occupational accident did not claim disability benefits according to the disability grade determined at that time, and thus received no compensation whatsoever for the existing disability, and only later, after the existing disability condition worsened and the disability grade changed, claimed a disability compensation pension according to the changed disability grade, such an unreasonable result of duplicate payment does not arise. Therefore, the Defendant should pay the disability compensation pension according to the number of days corresponding to the disability compensation pension for the changed disability grade, from the month following the month in which the date of cure following re-treatment medical care falls, and may not, on the basis of the instant provision, withhold payment of the disability compensation pension for a period equivalent to the number of days for which a disability compensation lump-sum payment according to the existing disability grade—which was never actually paid to the worker—would have been calculated. This same reasoning applies equally where the right to claim disability benefits for the existing disability grade was extinguished by completion of the extinctive prescription period while the worker failed to file such a claim. There is likewise no possibility of duplicate payment in such a case, and this is also consistent with the language of the instant provision, which refers to "the number of days for which the disability compensation lump-sum payment already paid was calculated" (see Supreme Court en banc Decision 2012Du26142, decided April 16, 2015).
B. According to the reasoning of the lower court judgment and the record, the following facts may be found.
(1) Around August 26, 2005, while the preceding medical care was ongoing, the Nonparty was diagnosed with "diabetic retinopathy" in both eyes, and received panretinal photocoagulation surgery on both eyes from around that time until October 21, 2015.
(2) On September 19, 2006, while the preceding medical care was ongoing, the Nonparty was diagnosed with "traumatic cataract" in the right eye and filed an application for re-treatment medical care with the Defendant. On September 22, 2006, the Defendant issued a non-approval decision on the ground that there was no proximate causal relationship between the Nonparty's traumatic cataract and the instant accident or the preceding injury/disease. Without raising an objection to the non-approval decision, the Nonparty underwent right eye cataract surgery on September 30, 2006.
(3) After the preceding medical care had ended, the Nonparty underwent "right eye corneal transplantation surgery" on April 18, 2011, and right eye vitrectomy and intravitreal injection on September 14, 2011.
(4) On November 15, 2016, the Nonparty again began receiving treatment for his right eye, and underwent right eye corneal re-transplantation surgery on February 7, 2017.
(5) On May 17, 2017, the Nonparty was diagnosed with right eye uncorrected visual acuity of hand motion perception, and on November 14, 2017, was diagnosed with right eye vitreous hemorrhage and right eye retinal detachment, and underwent right eye vitrectomy and other procedures.
(6) The medical record appraiser for the first instance court opined that "the preceding injury/disease may cause damage to the cornea and retina, and if ulceration and perforation occur, endophthalmitis may also occur, and complications such as cataract may also develop. It is difficult to explain the cause of the instant disability by any single one of the preceding injury/disease, senile cataract, or diabetic retinopathy alone."
(7) The medical certificate dated September 18, 2006, issued by an ophthalmologist at □□□□□□ ◇◇◇ Hospital, states to the effect that there is a high possibility that the Nonparty's cataract was aggravated by the instant accident.
(8) In response to the lower court's fact-finding inquiry, the director of □□□□□□ ◇◇◇ Hospital replied to the effect that "although it is difficult to recognize a direct causal relationship between the instant accident and the right eye corneal transplantation surgery performed on April 18, 2011, the cause of the Nonparty's loss of vision is corneal opacity and retinal detachment, and chemical damage caused by the instant accident may cause corneal opacity, cataract, etc. The corneal opacity and retinal detachment appear to have worsened after the cataract surgery on September 30, 2006, and this is presumed to be due to the combined effect of the instant accident and diabetes. Given that the left eye showed a relatively favorable course, diabetic retinopathy alone cannot explain the poor course of the right eye. The cause of the deterioration of vision in the right eye may be found in the instant accident."
C. In light of the circumstances surrounding the onset of the preceding injury/disease, its subsequent course, and the medical opinions regarding the cause of the instant disability as set forth above, even if the preceding injury/disease is deemed to have been cured with the symptoms fixed as of September 30, 2005, the date the preceding medical care was concluded, there is substantial room to view that it thereafter worsened beyond the natural course of progression, resulting in the onset of conditions such as "retinal detachment of the right eye" and a condition requiring re-treatment medical care. If such is the actual state of facts, then even if the Nonparty did not actually receive re-treatment medical care benefits because he failed to apply for re-treatment medical care benefits for the "retinal detachment of the right eye," etc. at an appropriate time, it should be deemed that he newly acquired a "right to claim disability benefits following re-treatment medical care" at the point when the symptoms became fixed and cured after receiving treatment for the "retinal detachment of the right eye," etc. at a medical institution, and that the extinctive prescription period began to run afresh from that point.
D. Nevertheless, the lower court, overlooking the circumstance that the Nonparty's preceding injury/disease worsened beyond the natural course of progression after the conclusion of the preceding medical care, thereby requiring re-treatment medical care, determined that the extinctive prescription period for the right to claim disability benefits ran from September 30, 2005, the date the preceding medical care ended, such that the three-year extinctive prescription period had already been completed by March 2, 2018, the date the claim for disability benefits was filed, and that the right to claim disability benefits regarding the instant disability had thus been extinguished. Such a determination by the lower court contains an error that affected the judgment, by misapprehending the legal principles concerning the "requirements for re-treatment medical care" and the "right to claim disability benefits following re-treatment medical care" under the former Industrial Accident Insurance Act, and thereby failing to conduct the necessary examination.
4. Conclusion
Therefore, the lower court judgment is reversed, and the case is remanded to the lower court for further hearing and determination. This judgment is rendered in accordance with the unanimous opinion of the participating Justices, as set forth in the Order.
Justice Kim Seon-su (Presiding Justice), Kwon Soon-il, Lee Ki-taek (Justice in Charge), Park Jeong-hwa