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(영문) 서울행정법원 2019.06.13 2018구합72093

업무정지처분취소

Text

1. Of the instant lawsuits, medical care benefit costs of KRW 111,378,790, June 15, 2018 of the Defendant National Health Insurance Corporation.

Reasons

1. Circumstances and details of the disposition;

A. The Plaintiffs are doctors who operated the “Ean Council member” in Seoul Gangnam-gu Seoul and D (hereinafter “instant Council member”).

B. On November 2015, the Defendant Minister of Health and Welfare (hereinafter “Defendant Minister”) conducted an on-site investigation as to whether the instant Council member’s claim for medical care benefit costs was appropriate (the period subject to investigation: from October 2012 to June 2014; from July 2015 to September 2015; hereinafter “instant on-site investigation”).

C. As a result of the instant on-site investigation, on the basis of Article 98(1)1 of the National Health Insurance Act, Defendant Minister suspended the business of medical care institutions for the Plaintiffs on April 24, 2018 (from December 17, 2018 to May 28, 2019) on the following grounds, based on the “National Health Insurance Act Article 98(1)1.”

(hereinafter referred to as the “instant disposition of business suspension”); double claims for medical care benefit costs and unfair claims for medicine costs after non-benefit medical treatment: KRW 225,442,30; KRW 227 under [Attachment Table 2] of Article 9(1) [Attachment Table 2] of the Regulations on the Standards for Medical Care Benefits in National Health Insurance; and perform vision correction to replace contact lensess, etc.; and even if the expenses were collected from persons who received the charge as non-benefit, they claim medical care fees, etc. as medical care benefit costs ( KRW 114,063,460); and - The medical care fees, etc. were collected from persons who received the charge as non-benefit; and the medical care fees, etc. were issued for medical care benefits and claimed pharmacy

D. Specific calculation of the period of business suspension of the instant case is as follows:

629,971,860 won 225,42,250 won 225,42,250 won 9,393,427 won 35.78% 163% 163% of the total amount of costs of health care benefit for the investigation period (from October 2012 to June 2014, July 2015 to September 2015, and 24 months).

E. On June 15, 2018, Defendant National Health Insurance Corporation (hereinafter “Defendant Corporation”) notifies the Plaintiffs of the restitution of medical care benefit costs of KRW 111,378,790 based on “Article 750 of the Civil Act” and at the same time notifies the Plaintiffs of the restitution of medical care benefit costs of KRW 114,063,460 based on “Article 57 of the National Health Insurance Act.”