실손의료보험의 보험약관 설명의무에서 '일반적으로 널리 알려진 사항'의 범위에 대한 연구

Abstract

The amount of Personal Health Insurance contracted and maintained is about 33 million and it is considered as a secondary National Health Insurance. As the clause on the Personal Health Insurance is changed every year, the conflict on the compensation between insurance company and insurance consumer is increasing. In this sense, There is a controversy on the carrying out the duty of explaining clause on Personal Health Insurance. some research argue that it is impossible for insurance planner to explain the duty exemption of standard clause on Personal Health Insurance, because the amount of the standard clause on Personal Health Insurance is too heavy and complicate, and also pointed out that providing too much information can make consumers confused. On the other hands, there are some arguments that if insurance planner does not explain the insurance clause when the insurance is contracted, there is no way to recognize and understand. According to the『Commercial Act』 and 『Act on the Regulation of terms and conditions』, “Important insurance clause” should be explained because the act does not specify which one is important in insurance clause. The case is continuously judged that the duty of explanation is exempted when insurance policyholder or claim representatives are familiar with the insurance policy, when it is general and common in transaction business without additional explanations, and when it is already determined in law. Among above three situations, the one that is general and common in transaction business without additional explanations is making disputes because it does not provide clear decision standard or the boundary is unclear. In this sense, this research investigated and analyzed the understanding and the recognition of the situation, ‘general and common in transaction business without additional explanations’ in each view of insurance consumer, insurance planner, and claim representatives regarding the following five types of primary dispute determined by the 30 claim representatives. ① Proportional compensation clauses on Personal Health Insurance ② Deductible amount of money clauses on medical expense ③ limitation of amount of money clauses on medical expense by day ④ Exemption clause on Personal Health Insurance ⑤ limitation of charge cap clause. The results revealed that most of the insurance consumers have low recognition of the primary dispute, and insurance planner group has the highest recognition on the clause explanation duty. Therefore this study found that five types of primary dispute cannot be considered as a situation ‘general and common in transaction business without additional explanations’