장기요양등급 판정과 간병보험금 청구권의 발생시점에 관한 연구 - 대법원 2023. 10. 12. 선고 2020다232709, 232716 판결을 중심으로 –

Abstract

The long-term care insurance contract is a third insurance product that pays insurance benefits according to the long-term care rating of the National Health Insurance Corporation under the Elderly Long-Term Care Insurance Act. The insurance terms and conditions stipulate that if the insured person is recognized as eligible for long-term care insurance for the elderly by the National Health Insurance Service during the insurance period, the insurance payment specified in the terms and conditions shall be paid. However, the insured person in this case died before submitting the application for long-term care grade and receiving the long-term care grade assessment from the National Health Insurance Corporation. The issue was at what point the deceased’s ‘long-term care level was determined’should be considered. However, in the special terms and conditions of this case, it is somewhat unclear at what point in time ‘when a long-term care grade has been determined’ is meant, leaving room for various interpretations. While the law clearly stipulates that recipients receive long-term care benefits, the special terms and conditions in this case do not clearly stipulate. There are several possible interpretations of these terms and conditions, and each interpretation is judged to be reasonable and persuasive. Therefore, it is appropriate to interpret this matter in favor of the contractor based on the literal interpretation of the terms or the contra proferentem. If the insured event date is determined based on the date the National Health Insurance Service makes a long-term care grade decision or the date the beneficiary receives the decision, the insured event date will be different for each individual insured person, which is unreasonable. In addition, when comprehensively considering the purpose and purpose of the long-term care insurance system for the elderly, the contents of the Elderly Long-term Care Insurance Act, and the differences between long-term care insurance, which is a private insurance, and public insurance, etc., the determination of long-term care level should be interpreted as having occurred at the time the deceased submitted an application for benefits to the National Health Insurance Service, before the deceased died. There is a need to revise the current terms and conditions to be more specific and clear to prevent unnecessary disputes related to long-term care insurance terms and conditions in the near future.