실손의료보험에서 본인부담상한제 환급금의 보상 범위 ― 대법원 2024. 1. 25. 선고 2023다283913 판결을 중심으로 ―

초록

This study critically examines the legal limits on exemption of amounts exceeding the out-of-pocket maximum in private health insurance, focusing on the Supreme Court Decision 2023Da283913 (January 25, 2024). The Court excluded such amounts from insurance coverage on the basis of the indemnity principle, even in the absence of an explicit exemption clause, holding that amounts subsequently reimbursed by the National Health Insurance Service do not constitute a "loss ultimately borne" by the insured. This study raises three critical concerns. First, applying the indemnity principle as a prerequisite that predetermines policy language effectively precludes the contra proferentem rule, raising significant issues in policy interpretation doctrine. Second, the out-of-pocket maximum system is a redistributive mechanism calibrated to income levels within the public insurance framework; when its effect determines the scope of private insurance benefits, disparities arise among policyholders paying identical premiums, distorting the risk-pooling principle. Third, while standard policy terms explicitly recognize exceptions to the indemnity principle for discounted medical expenses, deriving an exemption for out-of-pocket maximum reimbursements solely through general principles raises questions regarding internal consistency of the policy framework. This study proposes a pre-payment and post-settlement structure as an alternative model, emphasizing that the conflict between the two systems should ultimately be resolved through legislative reform of the cost allocation structure between public and private insurance.

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