Does the victim have to pay compensation if the hospital bills have been paid by insurance?

1. Basis for arising liability for compensation for damages in criminal cases

Liability for compensation for damages in criminal cases only arises when the following grounds exist:

- Illegal acts that cause damage to the life, health, honor, reputation, dignity, property, and legal rights of others. This includes any action or inaction that affects the rights of others and may involve violations of civil, criminal, and administrative laws...

- Actual damage occurred: To apply the liability for compensation for damage, it is necessary to clearly identify and prove the actual damage. Damage can be material or spiritual loss, existing objectively in reality.

- The causal relationship between the illegal act and the actual damage: This is a relationship that does not depend on the subjective will of the person. The illegal act is the cause of the damage and the damage is the result of that illegal act. Damage cannot appear without the act that causes it.

2. Does the victim whose hospital bills have been paid by insurance have to pay compensation?

As prescribed in Section I Resolution 02/2022/NQ-HDTP of the Council of Judges of the Supreme People's Court on liability for compensation for non-contractual damages, clearly stipulates the claim for compensation for damage when health is damaged. The injured person must clearly adjust each specific damage that has occurred, and must have evidence or valid receipts for reasonable expenses. In addition, they also need to prove their income during the claim for compensation according to the provisions of law.

Damages for health damage will include actual expenses necessary for treatment, rehabilitation, and restoration of health and lost functions. This includes expenses such as emergency costs at medical facilities, medicine, medical equipment, various types of x-rays, ultrasounds, tests, surgeries, blood transfusions, physical therapy as prescribed by a competent physician, hospital fees, supplements and health recovery as prescribed by a physician, as well as expenses for the restoration of lost or reduced body functions such as prosthetic legs, artificial eyes, and purchase of support devices to replace lost or reduced body functions.

According to Article 590 of the 2015 Civil Code, a person who causes damage to another person’s health must be responsible for compensation. In addition, the person causing the damage must also compensate an amount not exceeding 50 times the basic salary prescribed by the State to compensate for the victim’s mental damage. From there, it is clear that there are many types of compensation for damage, requiring different costs.

According to the provisions of Article 23 of the Consolidated text of the Law on Health Insurance 2020There are cases that are not covered by health insurance: such as health check-ups for testing and diagnosing pregnancy not for treatment purposes, using cosmetic services, or medical examination and treatment of mental damage caused by the person's own illegal acts.

Pursuant to the provisions of Article 33 of Law on Insurance Business 2022, the insured will receive insurance money within the scope of the insurance agreed in the contract, based on the cost of medical treatment and rehabilitation caused by illness or accident, and agreed in the insurance contract. In the event that the insured dies or is injured directly or indirectly due to the actions of a third party, the insurance company must still pay the insurance money without requiring the third party to reimburse the amount paid to the insured. The third party will be responsible for compensation according to the provisions of law.

Since the health insurance fund covers the hospital fees during the damage handling process, the injured party is not responsible for paying the hospital fees for himself when he has received support from the health insurance agency according to the provisions of law. This means that the injured party does not need to take care of the medical expenses arising from the treatment and recovery.

Hospital expenses for treatment in the hospital are one of the health consequences that the victim must bear due to the illegal act of the person causing the damage. The legal relationship here is about compensation for damages, which is regulated by the civil law on compensation for damages outside the contract. According to the provisions of the civil law, compensation for damages outside the contract is the legal responsibility that the person causing the damage must bear.

The insurance agency's payment of hospital fees to the victim originates from the insurance service contract relationship between the victim and the insurance agency, which is regulated by the Health Insurance Law. In other words, the health insurance agency's payment of hospital fees to the victim is an independent responsibility in the health insurance relationship between the victim (health insurance participant) and the health insurance agency when there is an insurance event that is not related to compensation for damages outside the contract.

Therefore, from the above analysis, we see that the relationship between compensation for damage caused by health infringement and the payment of hospital fees by the insurance agency are two independent legal relationships, regulated by independent fields of law. Thus, in this situation, the person causing the damage (the defendant) must be responsible for compensating for the hospital fees paid by the health insurance agency. At the same time, the fact that the prosecution agencies do not include the health insurance agency in the proceedings is in accordance with the provisions of law.