○○○○

Attorney ○○○, ○○○○

Attorney Kim Jae-soo ○○

Seocho-gu Seoul Metropolitan Government Seocho 3 Dong 1586 - 7

○○○○○

Law Firm OOO

○○, ○○, ○○

2. The costs of appeal shall be borne by each party.

피고가 2007. 3. 5. 원고에 대하여 한 ▥▥▥에 관한 진료비 18, 124, 979원의 환불처분

(b) revoke this subsection.

2. Purport of appeal

A. The plaintiff;

The part against the plaintiff in the judgment of the court of first instance shall be revoked. The defendant's kis against the plaintiff on March 5, 2007

The disposition of refund of KRW 17,274,957 with respect to medical expenses shall be revoked.

B. Defendant

The part against the defendant in the judgment of the first instance against the defendant shall be revoked, and the plaintiff's claim corresponding to the revoked part

The dismissal is dismissed.

가. 원고는 국민건강보험법 소정의 요양기관인 가톨릭대학교 부속 서울성모병원 ( 이하 ' 원고 병원 ' 이라 한다 ) 을 개설 · 운영하고 있고, 망 ▥▥▥은 2003. 1. 경 원고 병원에서 급성골수성백혈병으로 진단받아 그 무렵부터 2003. 8. 경까지 4차례 입원하여 치료를 받았다 .

나. 원고 병원의 의료진은 ▥▥▥의 백혈병 치료를 위하여 항암화학요법 및 조혈모 세포 이식술을 시행하였다. 조혈모세포 이식술은 혈액에 있는 백혈병세포를 제거하고 새로운 조혈모세포를 이식하는 치료방법으로서 ① 골수 및 척추천자 검사 → ② 중심정맥관 삽입을 통한 수혈, 항암제의 투여 → ③ 관해 ( 백혈병 환자의 골수와 말초혈액에서 백혈병 세포가 완전히 제거되는 것 ) 유도요법 → ④ 관해 후 요법 → ⑤ 조혈모세포 이식 및 생착의 단계를 거쳐야 한다 .

다. ▥▥의 아버지 □□□는 당시 진료비로 합계 34, 683, 483원을 원고 병원에 지급하였다가, ⅢⅢⅢ이 사망한 후 2006. 12. 경 피고에게 위 진료비가 국민건강보험법 소정의 요양급여의 대상에서 제외되는 것인지에 대하여 확인을 요청하였다 .

D. As a result of the Defendant’s examination upon the above request for verification, it confirmed that the Plaintiff hospital was paid an amount equivalent to KRW 18,124,979 in total to KRW 18,9 in violation of all the provisions on the criteria for medical care benefits and methods of medical care benefits at the time when the Plaintiff hospital treated Class III, such as the Rules on the Standards for Medical Care Benefits in National Health Insurance (amended by Ordinance of the Ministry of Health and Welfare No. 377, Dec. 29, 2006; hereinafter “the Benefit Standard Rules”), the health insurance act and the point of relative value (public notice given by the Ministry of Health and Welfare), and the criteria for calculating the purchase amount of medicine and materials for medical treatment (public notice given by the Ministry of Health and Welfare).

E. Accordingly, on March 5, 2007, the Defendant notified the Plaintiff of the amount equivalent to the above amount of the medical expenses that the Plaintiff hospital received from △△△, etc., on the ground that the expenses other than the co-payment under Articles 39(1) and 41 of the National Health Insurance Act (amended by Act No. 9932, Jan. 18, 2010; hereinafter the same) are excessive personal charges not falling under the expenses under the non-payment item under Article 39(3) of the National Health Insurance Act, on the ground that the expenses are excessive personal charges not falling under the expense under the non-payment item under Article 39(3) of the National Health Insurance Act (hereinafter the “disposition”).

F. In rendering the instant disposition, the Defendant classified the type of unfair collection of excessive personal charges as follows.

① Although medical care benefit costs are claimed in excess of the standard amount of medical care benefit, in light of the past review case, the Defendant is likely to be reduced in the process of examining the medical care benefit costs, without claiming the Defendant from the Defendant, to collect the cost of health care benefit to be claimed (5,081, 752 won; hereinafter referred to as “Type A illegal collection”).

② Although separate calculation of the cost of materials for medical treatment includes the cost of materials for medical treatment in the separate collection standard for medical care benefits, it is prescribed that it cannot be calculated separately. However, medical treatment, such as an aggregate testing, central beer inserting surgery, etc., is conducted, and the cost of the materials is separately collected (hereinafter referred to as “unlawful collection in Type B”).

③ The Commissioner of the Korea Food and Drug Administration with respect to the efficacy, efficacy, effect, dosage, etc. of a drug that collects expenses for a drug uses the relevant drug to a patient in violation of the medical care benefit standards, such as matters permitted by the Commissioner of the Korea Food and Drug Administration, and the collection of the relevant medical expenses (6,30,565 won; hereinafter referred to as “Type C illegal collection”); and the medical treatment subject to the aforementioned Category B or C illegal collection (hereinafter referred to as “voluntary non-benefit medical treatment”).

④ The elective medical care costs are collected from a comprehensive delegation that is not deemed to have filed an application for selective medical care (hereinafter referred to as “unauthorized collection of D type D”) by requiring the elective patient to file an application for selective medical care only with the main medical care department, and delegating the main medical care department and selective doctor with respect to selective medical care. Moreover, by collecting selective medical care costs from the main medical care department as well as the selective medical care department, it is not deemed that an application for selective medical care was filed (hereinafter referred to as “unauthorized collection”).

(5) Adjustment of other errors in calculation 2,756 won

[Ground of recognition] Unsatisfy, Gap evidence Nos. 1, 2, and 3, and the purport of the whole pleadings;

A. (1) With respect to the absence of the grounds for disposition (1) of the instant non-benefit medical treatment (type B and C unfair collection), substantial part of the instant non-benefit medical treatment constitutes the health care benefit subject or statutory non-benefit medical treatment subject after the amendment of the medical care benefit standard. If the law were amended favorable to the Plaintiff, the new law ought to be applied. Therefore, the instant disposition based on the previous law is unlawful.

(B) ① There was no prior procedure to include the instant non-benefit treatment in the medical care benefit subject to the medical care benefit. Even if there was such procedure, there was no time to undergo such procedure in light of the unique characteristics and seriousness of the treatment for leuk-patient patients. ② The instant non-benefit treatment can be said to have been proven in advance, ex post, medical stability, validity, and necessity based on various thesiss, clinical trial results, and the results of examination by the relevant administrative agency, and ③ the Doi Doi (the guardian of the patient) consented to the cost of the instant non-benefit treatment. Accordingly, the medical expenses received in return are justifiable and cannot be deemed to constitute excessive personal charges. (2) Even if the Plaintiff filed a request for examination with the Defendant, it is clear that the costs of the instant non-benefit treatment should be reduced due to the reason that the Plaintiff constituted a type B or C unfair collection. Therefore, it is also apparent that the Plaintiff’s request for examination constitutes an illegal collection of Type A type B or C type C type B.

(3) As regards the selective medical expenses (D unfair collection), the selective medical expenses are legally non-legal costs, and the defendant has the substantial right to review the selective medical expenses.

At the time of this hospitalization, Cheongsung comprehensively delegated the main medical care and selective doctor whether or not the selective medical care is provided and the designation of doctors is legitimate in light of the principle of private autonomy.

(b) the deviation and abuse of discretionary authority;

In light of the following: (a) the Plaintiff hospital’s medical treatment of an incurable disease, such as leuk dysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysysys

3. Relevant statutes;

As shown in the attached Form.

4. Determination

가. 이 사건 임의 비급여 진료행위 ( B형, C형 부정징수 ) 에 관하여 ( 1 ) 인정사실 ( 가 ) 이 사건 임의 비급여 진료행위 내역이 사건 임의 비급여 진료행위의 내역을 ▥▥▥의 입원기간별로 분류하면 아래 표 기재와 같다 .

(B) Details of voluntary non-payment related to B unfair collection and medical care benefit standards

○○ YE - MARW BOPSY is an essential diagnosis method for the diagnosis and treatment effect judgment of blood cancer, and evaluation of the U.S. residual disease, which is repeatedly implemented in the long-term treatment process of lebal diseases. The Plaintiff hospital used a single-use lebal bomy for the purpose of reducing patient infection and relaxing pains at the time of the examination, compared to the recycling of the lebal balthal balthal balthal balthalthal balthal balthalthal balthalthal balthalthalthal balthalthal balthalthy, and collected the expenses separately from the patients. However, the health care benefit standard is deemed to be recycled, and its materials are included in the lebalthal balthal balthal balthal balthal and it is not recognized as a separate benefit (except for non-legal benefits from January 1, 2008).

The amount of 00,000 p.m. injections of h.e., h., g., g., g., g., g., g., g., g. g., g., g. g., g., g. g., g. g., g., g. g., g., g. g., g. g., g. g., g. g., g. g., g. g., g. g., g., g. g., g. g., g. g., g. g. g. g., g. g. g., g. g., g. g., g. g. g., g. g. g.

○ 냉동보관료는 자가조혈모세포를 환자에게 이식하기 위하여 우선 말초조혈 모세포를 채집한 다음 이를 냉동보관하면서 발생하는 비용이다. 원고 병원에서는 2, 3차 입원기간에 각 3회씩 ▥▥▥의 말초조혈모세포를 채집하여 이를 냉동보관하였다 .

However, in the medical care benefit standards, freezing storage fees are not calculated according to freezing treatment recovery, but only one time per steering cell procedure is calculated.

○ RBC PURGING & STEM CELL WASHING ( 적혈구 제거 및 세척 ) 은 냉동보 관된 말초조혈모세포를 해동하여 이식하기 전에 말초조혈모세포에 포함되어 있는 항응 고제, 뼛조각을 세척하는 등의 생체외 처리과정이다. 원고 병원에서는 2, 3차 입원기간에 각 3회씩 끼의 말초조혈모세포를 채집한 후 생체외 처리과정을 거쳤다. 그런데 요양급여기준에서는 생체외 처리는 조혈모세포 이식료에 포함되어 있기 때문에 생체외 처리를 마친 말초조혈모세포를 이식하지 않는 경우의 생체외 처리비용은 따로 인정되지 아니한다 .

00 CEL PCRSING SET is a material used in the process of treating the products outside the living body of a horse early-blier cell. The medical care benefit standard is included in injection materials, etc., and it is not recognized as a separate material cost.

(C) Details of voluntary non-payment related to C unfair collection and medical care benefit standards

○○ Kadi District Court’s “The purpose is to prevent the cardio-pactic side effects that may arise in the event of administration of an anti-pactacinary climatic cancer to patients suffering from letropha. The Plaintiff hospital administered each 500ml per Ⅲ for the period of 1, 2, and 3 hospitalization. However, the health care benefit standard is not recognized as benefits or legal non-benefits except for the case of use for patients suffering from etropha (Provided, That some benefits are recognized from July 1, 2007).

○ ' 에글란딘 ' 은 항암치료 후 발생하는 구강점막염을 치료하기 위한 약제로서 효과적이라는 임상 사례보고가 있다. 원고 병원에서는 1 ~ 4차 입원기간 동안 1 ~ 2ml의 에글라딘을 ▥▥에게 투여하였다. 그런데 요양급여기준에서는 위 약제가 만성 동맥폐색증에 의한 사지궤양 및 안정시 통증의 개선을 위한 목적으로 사용하는 경우 외에는 급여 또는 법정 비급여로 인정되지 아니한다 .

There are domestic and foreign research cases that are effective to reduce the generation, depth, and imbalance of sacrine administration, which are the side effects of an existing sacratism administered to prevent the sacratitis of patients with brue diseases, and to reduce the sacratization of sacratum, which is the effective side effects of sacratism.

However, the medical care benefit standard is that the Indian business owner is permitted for the purpose of supplying energy and essential local products, and it is not recognized as benefits or legal non-benefits to combine the White-related patients with Ethlass and decoration standards.

○ Opmon is designed to prevent any cryp matho that may occur after the hemal stem cell transplantation. However, in the medical care benefit standard, the purpose of this medical care benefit standard is to improve the symptoms of her Hemmon, such as cryp caused by pulmonary hemosis (pulmonary hemosis infection), and it is not recognized as benefit or legal non-benefit (Provided, That it is recognized as partial non-benefit from October 1, 2007 to some non-benefit).

The purpose of ○○○ is to prevent multi-long-term cell toxicity in enforcing the Chemical Act including the cropospam. However, the medical care benefit standard is permitted for the purpose of preventing side effects that may be caused by the treatment for patients with ambane and two ambane, and it is not recognized as benefits or legal non-benefits for patients with lebane. (D) The prior procedure for adjusting the medical care benefits, etc. established in the medical care benefit standard for the prior procedure for the adjustment, etc. of medical care benefits is as follows.

(1) A medical care institution, medical care institution, medical organization, or manufacturer or importer of a material for medical treatment shall apply to the Minister of Health and Welfare for the determination of whether a new act or material for medical treatment has been subject to health care benefit or non-medical treatment within 30 days from the date the first act was conducted by the subscriber, etc., or the Commissioner of the Korea Food and Drug Administration obtained an item approval or notified an item of the material for medical treatment from the Commissioner of the Korea Food and Drug Administration, and the Minister of Health and Welfare shall determine and publicly notify whether a person falls under the health care benefit subject or non-medical treatment subject after deliberation by the Health Insurance Policy Deliberative Committee (see Articles 10 and 11 of the Benefit Standard Rules). This procedure was introduced and implemented along with the enactment of the benefit standard rules on June 30, 200, which is not an existing act, medicine, or material for medical treatment and needs to be used beyond the health care benefit

(2) An applicant for decision-making, such as the adjustment of relative value points, etc., or an insured person, etc., need to adjust the relative value points of an act because of a significant change in the quantity of duties or the quantity, price, etc. of resources included in the act, or where there is any unreasonable reason in the classification between the medical care benefit subject and non-medical care benefit subject, an application may be filed with the Minister of Health and Welfare under the conditions as determined and publicly notified by the Minister of Health and Welfare. The Minister of Health and Welfare, upon receipt of an application for mediation, may adjust and publicly notify the upper limit of relative value points, medical care benefit subject and non-medical benefit subject to the adjustment (see Article 12 of the Regulations on the Standards for Benefits, Article 3(2) of the Decree on the Determination and Adjustment of New Medical Technology, etc.). This procedure was introduced at the time of enactment of the Benefit Standard Rules on June 30, 200, not the procedure of regulating the classification of benefits and non-legal benefits, and not the new procedure

③ The Regulations on the Standards for Benefit of Special Procedures for Drugs (amended by Ordinance of the Ministry of Health and Welfare No. 328, Oct. 11, 2005; hereinafter referred to as the “Rules on the Standards for Benefit of Special Procedure Concerning Drugs”) made it possible to administer medicines beyond the permissible scope under pharmaceutical statutes if particularly necessary for the treatment of serious patients (see attached Table 1); and (a) the standards and methods for applying medical care benefits under Article 3-1(2) and (3) for the enforcement of the above provisions; and (b) until August 30, 2007, a public announcement of blood disease, such as dead cancer and leuk-celle cells, and the Act on Treatment before the transplantation of dead-parent cells cells, was issued in order and implemented effectively thereafter (the system for applying for non-benefit for general medicine).

1. It shall be introduced and enforced from the date of introduction and enforcement).

(e) As to the consent of the winner

① ▥▥은 원고 병원에 입원할 때 " 입원치료 중 긴급수술이나 검사가 필요한 경우, 귀 병원에서 보호자의 사전 동의 없이 시행한 진료행위 ( 국민건강보험 요양급여 대상에서 제외되고, 진료상의 진단 및 치료에 필요한 비급여 항목 포함 ) 에 대해 이의를 제기하지 않으며 진료상 발생하는 모든 문제와 수술 또는 그 후에 일어나는 모든 문제에 대하여 병원 측의 명백한 진료과실이 있는 경우를 제외하고는 병원 측에 민 · 형사상 책임을 묻지 않음은 물론, 만일 분쟁이 생겼을 시 의료법 제54조 제2항에 의거 의료심사조정위원회에 그 조정신청을 하겠습니다. " 라는 내용이 기재된 입원약정서 ( 갑 제11호증 ) 를 작성하였고, □□□는 보호자로서 이를 연대보증하였다 .

② In addition, the Plaintiff hospital received the notarial deed (No. 12 No. 12) from Gisung (the document), and the said deed, “3. The guardian is responsible for the treatment of the above patient and the medical expenses incurred by the procedure related thereto, and provided sufficient explanation as to the following matters. A. Even if the insured is the insured, a person who is not subject to the health insurance benefit standard may not be the health insurance benefit. (b) Even if the approval of the transplant of the protoma cell was granted, there may be any portion of the restriction on benefits that is not recognized in the health insurance benefit standard, and this does not raise any objection against the entire insured (patient).

[Ground of Recognition] Unsatisfy, Gap evidence 11, 12, Eul evidence 4, and the court of first instance

As a result of the entrustment of appraisal of medical records to the president of the Korean Embrymology cell transplantation, the overall purport of the pleadings (2) related legal principles

According to Articles 41 and 43-2 of the National Health Insurance Act, the insured, etc. of the National Health Insurance may request the Defendant to verify whether the expenses borne by the insured, etc. of the national health insurance in addition to the amount of co-payment to be borne by themselves under the conditions as prescribed by the Presidential Decree are excluded from the amount of the health care benefit under Article 39 (3). Upon receipt of such request, the Defendant shall notify the relevant health care institution of the purport that the expenses required for confirmation constitute the expenses for the subject of the health care benefit, and the notified medical care institution shall pay the excessive amount without delay to the person who requested the confirmation. In examining the system under the National Health Insurance Act, such as the subject of the health care benefit, the standard and procedure for payment, the statutory principle on the non-payment, etc. based on the purport of the national health insurance system, the health care institution is not the so-called non-payment medical care institution, which

(2) The scope of excessive charges to be confirmed by the Defendant under Article 43-2 (1) and (2) of the National Health Insurance Act includes not only “expenses paid in excess of the amount of co-payment to which the insured, etc. should bear under the conditions and procedures prescribed by the Presidential Decree” but also “expenses paid in mutual agreement with the insured, etc. regarding non-payment treatment without complying with the said standards and procedures” in principle (see, e.g., Supreme Court en banc Decision 201Du3524, Aug. 17, 2012). However, given that the medical care institution is not obliged to provide the best medical treatment to the insured, etc. in accordance with the relevant medical treatment contract with the insured, and it is difficult for the medical care institution to reasonably explain the relevant excessive charges to the insured, etc. Furthermore, even if it is deemed that the medical care institution has no choice but to bear the medical care expenses, such as providing the medical treatment expenses at its own discretion, and thus, it is difficult for the medical care institution to view such excessive charges as effective and effective.

In light of the principle of the rule of law and the provisions of Article 13 of the Constitution, barring special measures, such as establishing transitional regulations that ensure that the new Act and subordinate statutes apply in favor of the persons subject to the amendment, the former Act and subordinate statutes shall be applied instead of the new Act and subordinate statutes after the amendment: Provided, That even if the new Act and subordinate statutes are retroactively applied, where there is no direct relation to the interests of the general public, and where there are special circumstances, such as promoting the benefit, or removing disadvantages or pain, the retroactive application of the amended Acts and subordinate statutes is exceptionally allowed (see Supreme Court Decisions 2001Du3228, Dec. 10, 2002; 2004Da8630, May 13, 2005, etc.). Therefore, barring any special circumstance, it cannot be deemed that the amended Act and subordinate statutes are retroactively applicable to the medical care institution, such as medical treatment and subordinate statutes, which were conducted by the medical care institution, and the expenses paid as the consideration fall under excessive shares under Article 43-2 of the National Health Insurance Act.

결국, 변경 전의 법령을 적용하여야 한다는 취지의 원고 주장은 이유 없다 . ( 4 ) 임의 비급여 진료행위의 정당성 여부에 대한 판단 ( 가 ) 사전 절차의 존부 등 위 인정사실 및 거시증거에 변론 전체의 취지를 종합하여 인정할 수 있는 다음과 같은 사정, 즉 ① 급여기준규칙에 의하면, 요양기관 등은 요양급여 대상 또는 비급여 대상으로 결정되지 아니한 새로운 행위 및 치료재료에 대하여 가입자 등에게 최초로 행위를 실시한 날 등으로부터 30일 이내에 요양급여대상 여부의 결정을 보건복지부장관에게 신청하여 보건복지부장관으로부터 요양급여대상 또는 비급여 대상의 해당 여부를 결정받을 수 있고, 또한 결정신청자 또는 가입자 등은 행위에 포함된 업무량 또는 자원의 양 · 가격 등이 현저히 변화되어 행위의 상대가치점수를 조정할 필요가 있거나 요양급여 대상과 비급여대상 사이의 분류에 불합리가 있는 등의 경우에는, 이미 고시된 요양급여 대상의 상대가치점수 상한금액, 요양급여 대상 · 비급여 대상의 조정을 보건복지부장관에게 신청할 수 있도록 규정되어 있으나, 앞서 본 바와 같이, 위 신의료기술 등의 결정절차는 기존의 행위 · 약제 및 치료재료를 요양급여기준을 벗어나 사용할 필요가 있는 경우에는 적용되지 아니하고, 상대가치점수 등의 조정절차도 급여와 법정 비급여의 분류 등을 조정하는 절차일 뿐 임의 비급여 진료행위를 급여 또는 법정 비급여 대상으로 새로 편입하는 절차는 아니며, 약제에 관한 특별절차도 2007년에 이르러서야 비로소 실효적으로 운용되기 시작하는 등 원고 병원이 ▥▥▥을 진료한 2003년 당시 요양급여의 조정을 위한 사전절차가 완비되어 있었다고 보기 어려운 점, ② B형 부정징수와 같이 요양급여기준상 골수천자검사, 중심정맥관 삽입수술 등 진료행위에 이미 치료재료 비용이 포함되어 있다거나, C형 부정징수와 같이 의약품의 효능 · 효과 및 용법 · 용량 등에 관한 요양급여기준을 위반한 의약품 사용이라 하더라도, 그 치료재료나 의약품 사용이 당시 ⅢⅢⅢ의 병세에 비추어 시급한 필요성이 있었던 반면에, 그 비용에 관하여는 원고 병원이 환자들로부터 그 비용을 징수하는 것 외에 달리 비용을 보전할 수 있는 실효적 방법이 없었던 점, ③ 설령 이 사건 임의 비급여 진료행위 중 일부가 위와 같은 요양급여의 조정을 위한 사전절차의 대상이 된다고 하더라도, 위와 같은 절차는 의료기관 등의 신청과 관계 기관의 심의 등을 거치는 등으로 상당한 시일 ( 최소한 5 내지 6개월 ) 이 소요될 것으로 보이는 반면, 당시 ⅢⅢⅢ에 대한 진료의 필요성은 시급하였던 점 등에 비추어, 원고 병원이 앞서 본 바와 같은 사전 절차를 거치지 않고 ⅢⅢⅢ에 대하여 이 사건 임의 비급여 진료행위를 하였다고 하여 위와 같은 사전 절차를 회피한 것이라고 보기는 어렵다 .

(B) Whether medical stability, effectiveness, and necessity are necessary

위 인정사실 및 거시증거에 변론 전체의 취지를 종합하여 인정할 수 있는 다음과 같은 사정, 즉 ① 백혈병 치유를 위한 조혈모세포 이식술은 이를 시행하는 과정에서 골수천자검사, 항암제 부작용 등으로 인한 환자의 고통이 극심하고, 면역저하로 인하여 경미한 감염에도 생명이 위태로울 수 있기 때문에, 이를 완화하고 예방할 수 있는 즉각적이고 선제적인 치료가 필요한 점, ② 골수천자검사에서 1회용 골수천자바 늘을 사용하는 것은 백혈병 환자의 감염 위험을 회피하고 골수검사 때의 통증을 감소시키기 위한 것으로서 2008. 1. 1. 부터 법정 비급여 항목에 포함된 점, ③ 백혈병 환자에게 항암제를 투여하기 위하여 삽입하는 중심혈관은 장기적으로 사용되거나 관리가 소홀할 경우 관류상태가 불량해지거나 막힐 수 있으므로 혈액응고를 방지하기 위한 헤파린 주사의 반복사용이 필요한 것으로 보이는 점, ④ 조혈모세포 이식시에는 이미 채집하여 냉동보관 중인 말초조혈모 세포를 녹여서 주입하게 되고, 이때 재발 및 합병증발생을 대비하여 일부 말초조혈모 세포를 계속 남겨두어 보관하는바, 원고 병원에서는 2, 3차 입원기간에 합계 6회에 걸쳐 ▥▥▥의 말초조혈모세포를 채집하여 이를 냉동보 관한 것이고, 그 과정에서 냉동보관 및 생체외 처리 비용이 발생한 것으로 보이는 점 , ⑤ 항암제인 안트라사이클린 약제의 고유한 부작용으로 심장독성이 유발될 수 있는데 , 카디옥산은 이를 예방하는 효과적인 약제로서 2007. 7. 1. 부터 비급여 항목 ( 일부는 급여 ) 에 포함된 점, ⑥ 구강 내 점막 손상은 항암치료 후 발생하는 흔한 합병증인바, 에 글라딘은 구강점막염의 예방 및 통증 완화, 치료에 효과적인 것이라는 내용의 임상 사례보고가 있는 점, ⑦ 인트라리 포즈주는 훈기존 주의 투여에 의한 발열, 오심, 구토 등의 부작용을 극복하고, 불충분한 영양을 공급하기 위하여 효과적이라는 국내외의 연구가 있는 점, ⑧ 오팔몬정은 백혈병 치료를 위한 면역억제제 사용 등으로 발생할 수 있는 간정맥폐색증 등의 부작용을 예방하는데 효과적인 약제로서, 2007. 10. 1. 부터 비급여 항목에 포함된 점, ⑨ 백혈병 환자에게도 시클로포스파미드를 포함한 항암화학요법을 시행하고 있고, 이 때 에치올은 다장기 세포독성의 예방을 위한 효과적인 약제가 될 수 있는 점 등을 종합하여 보면, 이 사건 임의 비급여 진료행위는 의학적 안전성과 유효성뿐 아니라 요양급여 인정기준 등을 벗어나 진료하여야 할 의학적 필요성, 즉 처치의 불가피성 또는 치료 진단 효과의 우수성을 갖추었다고 볼 수 있다 . ( 다 ) 설명 및 동의 여부

Ⅲ Ⅲ and his guardian Ⅲ have written a written agreement of hospitalization to the effect that the Plaintiff hospital would not raise any objection to the medical expenses while being hospitalized, and the fact that the Gitoe may cause part of the benefit limitation that is not recognized in the health insurance medical care benefit standard, and that the Gitoe may, at the expense of the patient, set up an application for the transplant of the same type of hemoto cell with the purport of not raising any objection to it, and submitted it to the Plaintiff hospital.

그러나 위 인정사실 및 거시증거에 변론 전체의 취지를 종합하여 인정할 수 있는 다음과 같은 사정, 즉 ① 국민건강보험법령상 요양기관은 법정 비급여 진료행위가 아닌 한 원칙적으로 요양급여의 인정기준에 관한 법령에서 정한 기준과 절차에 따라 요양급여를 제공해야 하고, 보험자와 가입자 등으로부터 요양급여비용을 지급받을 때에도 그 산정기준에 관한 법령에서 정한 기준과 절차에 따라야 하는 것이며, 임의비급여 진료행위에 대하여 수진자 측으로부터 그 비용을 징수하는 것은 원칙적으로 허용되어서는 안 되는 점, ② 임의 비급여 진료행위는 환자의 국민건강보험수급권을 침해할 수 있으므로, 원고 병원으로서는 의학적 필요성이 있는 것으로 판단하였더라도 각 진료행위의 의학적 적합성, 소요 비용, 국민건강보험의 틀 내에서 다른 대체적 진료 수단이 있는지 여부 ( 불가피성 ), 대체적 진료수단이 있는 경우라면 그럼에도 이를 선택하지 않고 임의 비급여 진료행위를 선택한 이유 ( 우월성 ) 등에 관하여 상세한 설명을 하고 동의를 받는 과정이 있어야 할 것인데, 이 사건 임의 비급여 진료행위에 관하여는 위와 같은 과정을 거쳤음을 인정할 자료가 없는 점, ③ 원고 병원이 ⅢⅢⅢ 등으로부터 제출받은 입원약정서 및 동종 조혈모세포 이식신청서에 기재된 " 건강보험 요양급여기준에서 인정하지 않는 급여제한 부분이 발생할 수 있다 " 는 문구는, 건강보험의 급여체계나 의학에 관한 전문적 지식이 없는 일반 환자들의 입장에서 그 의미를 정확히 알기가 어려운 것일 뿐만 아니라, 오히려 일반 환자들의 입장에서는 위 문구가 " 요양급여 대상에 해당하지 않는 법정 비급여 대상이 있을 수 있다 " ( 소위 ' 보험으로 안 되는 것이니 본인 부담으로 해야 한다 ) 는 취지로 이해될 여지가 충분한 점이 사건에서도 □□□는 자신이 본인 부담금으로 지급한 진료비가 국민건강보험법 소정의 요양급여의 대상에서 제외되는 것 ( 법정 비급여 대상 ) 인지에 대하여 확인을 요청한 것이다 ), ④ 원고 병원이 ▥▥▥ 등으로부터 위와 같은 입원약정서 및 동종 조혈모세포 이식신청서를 받을 당시, 향후 이루어질 각 진료행위와 재료비용, 의약품 등에 관하여 구체적으로 어느 범위의 것이 요양급여대상이나 법정 비급여대상에 해당하는지, 따라서 어떤 사항이 요양급여 또는 법정 비급여 대상에서 제외되어 임의 비급여 진료행위로서 실시되는 것인지 등에 관하여 충분한 설명을 해 주었다고 인정할 아무런 자료가 없는 점, ⑤ ㅁㅁㅁ가 작성한 동종 조혈모세포 이식신청서의 내용은, 조혈모세포 이식술과 관련한 일련의 치료절차에서 다양한 형태의 진료행위가 이루어질 수 있음에도, 진료비가 본인 부담으로 될 경우 사전에 포괄적으로 본인의 비용부담을 전부 동의한다는 취지인데, 건강보험의 급여체계나 의학에 관한 전문적 지식도 없고 난치병에 걸린 곤궁한 처지에 있는 환자나 보호자가 위와 같은 포괄적인 내용의 동의서를 작성한 것만으로는, 개개의 임의 비급여 진료행위의 내용 및 비용에 관한 충분한 설명을 들어 이해한 후 그러한 동의를 한 것으로 보기 어려운 점 등의 사정을 종합하여 보면, 원고 병원이 ▥▥▥ 등으로부터 위와 같이 입원약정서, 동종 조혈모세포 이식신청서를 작성받았다고 하여 그것만으로는 이 사건 임의 비급여 진료행위의 내용과 비용에 대하여 충분히 설명하여 본인 부담으로 진료받는 것에 대하여 동의를 받았다고 인정하기에 부족하고, 달리 이를 인정할 증거가 없다 .

(5) Sub-decisions

Therefore, since the medical expenses for the instant non-paid medical treatment cannot be deemed an exceptional circumstance that cannot be deemed as an excessive personal charges, the Plaintiff’s assertion on a different premise is without merit.

B. According to the above facts and macroscopic evidence with regard to the illegal collection of Type A, the Plaintiff hospital may recognize the fact that the Plaintiff fell under the subject of the claim for medical care benefit costs under the medical care benefit standard and the Defendant collected the medical care benefit costs of KRW 5,081,752 to the Defendant without requesting the Defendant to do so, and the following circumstances can be recognized by comprehensively considering the overall purport of arguments in the above facts and macroscopic evidence. In other words, as long as a medical care institution under the National Health Insurance Act provides medical care benefits according to the standard and procedure stipulated in the Act on the Criteria for Recognition of Medical Care Benefits and receives medical care benefits from the insurer, the insurer, the insured, etc., should, in principle, comply with the standard and procedure stipulated in the above calculation standard, even if the medical care benefits are provided and the medical care benefits are paid by the insurer, etc., and as such, the act of receiving the expenses from the recipient of the medical care benefits can not be permitted in accordance with the agreement with the recipient of the medical care benefits.

C. On June 26, 2003, ○○○○○ (A) entered the selective medical examination and treatment application form with the content of selective medical examination, treatment, surgery management, examination, image diagnosis, radiation treatment, anesthesia, and mental and physical method into the selective medical examination and treatment application form with the content of selective medical examination and treatment as “SNS in the medical department where each public space is public space” and “SNS in the selective medical doctor’s name column” respectively.

(B) At the time, the application form for the selective medical treatment written by Dog Dog Dog Dog Dog Dog Dog Dog Dog Dog Dog Dog Dog Dog-do Dog Dog Dog Dog Dog Dog Dog Dog Dog Dog dog Dog Dog Dog Dog Dog dog Dog dog Dog Dog do

[Grounds for Recognition] Uncontentious Facts, Entry of Evidence No. 4, and Determination of the purport of the whole pleadings (2)

According to the former Medical Service Act (amended by Act No. 8067, Oct. 27, 2006; hereinafter the same), a patient or his/her guardian (hereinafter referred to as “patient, etc.”) may select a specific doctor, etc. of an elective medical institution prescribed by statutes, such as a general hospital. In such cases, the head of the medical institution shall require the patient, etc. to provide elective medical treatment, barring any special circumstance. The head of the medical institution may, in principle, collect additional expenses from the patient, etc., even if he/she allows elective medical treatment by meeting certain requirements, but may collect additional expenses in exceptional cases where elective medical treatment is allowed by meeting certain requirements (Article 37-2(1), (3), and (4)). The former Medical Service Act delegated the qualification requirements for and scope of a medical institution to collect additional expenses, standards for calculating items and additional expenses for elective medical treatment, and other necessary matters to determine elective medical doctor’s elective medical treatment, etc. (Article 37-2(5)).

In this case, the following circumstances can be acknowledged by comprehensively considering the purport of the argument in light of the aforementioned facts, the above facts, and macroscopic evidence, i.e., (i) the patient, etc. can file an application by dividing the selective medical treatment subject into the doctor in charge of selective medical treatment, and (ii) the patient, etc. may delegate the selective medical treatment subject to selective medical treatment to the doctor in charge of selective medical treatment. However, the Plaintiff hospital, using such selective medical treatment form, provides the doctor requesting selective medical treatment with his/her intention in charge of selective medical treatment and submitted the selective medical treatment, and (iii) consented to entrusting the doctor in charge of selective medical treatment with the selection of the doctor in charge of selective medical treatment in charge of selective medical treatment with the doctor in charge of selective medical treatment, in light of the fact that the Plaintiff hospital appears to have undergone the procedure of explaining the patient, etc. in the process, and that the Plaintiff hospital appears to have not been able to have been able to ask the doctor in charge of selective medical treatment and the doctor’s right of selective medical treatment, etc.

D. As to the assertion of deviation from or abuse of discretionary power, whether each of the dispositions in this case deviates from or abused the discretionary power, the relationship between the National Health Insurance Act and Article 43-2 of the National Health Insurance Act, which form the basis of the disposition.

In full view of the contents and purport of the statutes, it is reasonable to view the above disposition as a binding act. Therefore, the Plaintiff’s assertion that the above disposition is a discretionary act is without merit. (On the other hand, the Plaintiff’s assertion that the extinctive prescription for the claim for refund of excessive principal charges, such as Magsung, has expired, and the instant disposition is unlawful. However, the instant disposition is in accordance with Article 43-2(2) of the National Health Insurance Act, and it is irrelevant to the completion of the extinctive prescription for the claim for refund of excessive principal charges against the Plaintiff, such as Magsung, and further, the claim for refund of excessive principal charges against the Plaintiff, such as Magsung, is a claim for return of unjust enrichment, and the ten

E. Sub-committee

Ultimately, the part concerning Category A, Category B, and Category C unfair collection among the instant dispositions is lawful, and the part concerning D unfair collection is unlawful. As such, the part of the instant dispositions exceeding KRW 17,274,957 ( = 18,124,979 - KRW 850,02) among the instant dispositions is unlawful.

5. Conclusion

Therefore, the plaintiff's claim of this case is justified within the above scope of recognition and the remaining claim is dismissed as it is without merit. The judgment of the court of first instance is just in this conclusion, and all appeals of the plaintiff and defendant are dismissed. It is so decided as per Disposition.

Judges Park Jong-tae

Judges Kim Yong-name

A person shall be appointed.

A person shall be appointed.

A person shall be appointed.

A person shall be appointed.