beta
(영문) 대법원 2016.05.27 2015두1922

과다본인부담금확인처분등취소

Text

All appeals are dismissed.

Costs of appeal shall be borne by each party.

Reasons

The grounds of appeal are examined.

1. Regarding the explanation and consent method of voluntary non-benefit medical treatment (the plaintiff's ground of appeal and the defendant's ground of appeal No. 2)

A. In light of the purport of the national health insurance system and the overall structure of the relevant statutes, health care institutions shall, in principle, provide health care benefit to subscribers, etc. according to the standards and procedures prescribed in the statutes on the criteria for recognition of health care benefit, unless so-called non-legal care benefit excluded from the subject of health care benefit under Article 39(3) of the former National Health Insurance Act (amended by Act No. 9932, Jan. 18, 2010; hereinafter the same) is not so-called non-legal care benefit. The payment of health care benefit from insurers, subscribers, etc. shall follow the criteria and procedures prescribed in the statutes on the criteria for calculation. As such, excessive charges that the Defendant must notify the subscribers, etc. of the criteria and procedures for recognition of health care benefit under Article 43-2(1) and (2) of the former National Health Insurance Act include not only “expenses received in excess of the amount of co-payment to be borne by the subscribers, etc. under the conditions and procedures prescribed by the Presidential Decree” but also includes “expenses under mutual agreement between the care benefit and non-payment.”

However, even in cases where a medical care institution conducts non-benefit medical treatment outside the framework of the National Health Insurance, and receives the expenses from policyholders, etc., ① such medical treatment is included in the relevant Acts and subordinate statutes implemented at the time of such medical treatment in the framework of the National Health Insurance, or relevant medical care benefit costs can be reasonably adjusted.