[2] In a case where Gap hospital designated as a local emergency medical institution failed to meet the human resources standard under attached Table 8 of the Enforcement Rule of the Emergency Medical Service Act that the number of nurses exclusively in charge of emergency medical institutions should be at least five, and the National Health Insurance Corporation received emergency medical management fees by providing first aid to patients, etc. who were continuously in an emergency room and received emergency medical management fees, the case holding that it is difficult to view Gap hospital’s emergency medical management fees received by Gap hospital as an object of unjust enrichment under Article 57(1) of the former National Health Insurance Act merely because Gap hospital did not meet the “ human resources standard exclusively in charge of emergency room” when it received first aid from patients who were in an emergency room, etc., and thus Gap hospital received emergency medical management fees by fraudulent or other unjust means

[2] In a case where Gap hospital designated as a local emergency medical institution received emergency medical treatment fees from Gap hospital based on Article 57 (1) of the former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter the same) on the ground that Gap hospital continued to provide first aid and emergency medical treatment to patients, etc. who were in an emergency room and received emergency medical treatment fees, although the number of persons in exclusive charge of nurses in the emergency room failed to meet the human resources requirements among the “standards for designation of local emergency medical institution” in attached Table 8 of the Enforcement Rule of the Emergency Medical Service Act, the case holding that since Gap hospital did not meet the “standards for human resources in exclusive charge of emergency room” at the time, it is difficult to view the first aid management fees received by Gap hospital as the subject of unjust enrichment or other expenses for emergency medical treatment under Article 57 (1) of the former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter the same)

1. Case summary

According to the reasoning of the lower judgment and the record, the following circumstances are revealed.

A. The “○○○ Hospital” (hereinafter “instant hospital”) which is a general hospital operated by the Plaintiff in the Chungcheongnam-gun budget group ( Address omitted) was designated as a local emergency medical institution on March 14, 2006 pursuant to the Emergency Medical Service Act (hereinafter “Emergency Medical Service Act”).

B. From around 2011, the instant hospital failed to meet the human resources standard (hereinafter “standards for human resources in exclusive charge of nurses in an emergency room”) that the number of persons in exclusive charge of nurses in an emergency room among the “standards for designation of local emergency medical institutions” in attached Table 8 of the Enforcement Rule of the Emergency Medical Service Act (hereinafter “Enforcement Rule of the Emergency Medical Service Act”), but has continued to provide first aid and emergency medical services to patients, etc. in an emergency room and received emergency medical treatment fees from the Defendant.

C. Based on Article 57(1) of the former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter “National Health Insurance Act”), the Defendant issued a disposition to collect charges for emergency medical service management of KRW 62,638,980 on December 29, 2016; and collect charges for emergency medical service management of KRW 107,707,590 on January 25, 2017.

2. Whether grounds for disposition are recognized (ground of appeal Nos. 1, 2, and 3)

A. Relevant legal principles

The National Health Insurance Act was enacted for the purpose of contributing to the improvement of national health and the promotion of social security by providing citizens with insurance benefits for the prevention, diagnosis, and rehabilitation of diseases and injuries, for childbirth and death, and for the improvement of social security (Article 1). Therefore, the legislative purpose and subject of regulation differs from other individual administrative Acts, such as the Emergency Medical Service Act. Therefore, whether the provision of medical care benefits and the receipt of medical care benefits by a medical care institution under the National Health Insurance Act constitutes “cases where the medical care institution received insurance benefits costs by fraud or other improper means” under Article 57(1) of the National Health Insurance Act should be determined by considering the legislative purpose and degree of the provision of insurance benefits under the National Health Insurance Act and other individual administrative Acts, in consideration of the difference between the legislative purpose and subject of regulation, and the legislative purpose of the provision of insurance benefits under the National Health Insurance Act and other individual administrative Acts (see, e.g., Supreme Court Decisions 2017Du59284, Nov. 28, 2019>

B. Details of the relevant statutes

1) Article 41(2) of the National Health Insurance Act provides that the standards, such as the method, procedure, scope, and upper limit of health care benefit, shall be prescribed by Ordinance of the Ministry of Health and Welfare. Accordingly, Article 5(1) of the Regulations on the Standards for Medical Care Benefits under National Health Insurance provides that health care institutions shall provide health care benefit for subscribers, etc. according to the standards and methods for the application of health care benefit under attached Table 1, and [Attachment Table 1] subparagraph 1(d) of the same Article provides that “medical care institutions shall maintain adequate human resources, facilities, and equipment necessary for health care benefit for subscribers, etc.

2) Article 31 of the former Emergency Medical Service Act (amended by Act No. 13436, Jul. 24, 2015; hereinafter “former Emergency Medical Service Act”) provides that the head of a Si/Gun/Gu may, in principle, designate a local emergency medical institution among general hospitals under the Medical Service Act (Paragraph 1); and that matters necessary for the designation standards of a local emergency medical institution shall be determined by Ordinance of the Ministry of Health and Welfare in consideration of the demand, supply, etc. of emergency medical services by a Si/Gun/Gu (Paragraph 2). Accordingly, Article 18(1) [Attachment 8] of the Enforcement Rule of the Emergency Medical Service Act provides that “the standards for facilities, human resources, and equipment of a local emergency medical institution shall be five persons or more exclusively in charge of emergency medical services while setting the standards for designation of a local emergency medical institution. Furthermore, the former Emergency Medical Service Act provides that an emergency medical institution shall maintain and operate facilities, human resources, equipment, etc. in accordance with the designation standards of an emergency medical institution so that it can treat an emergency patient for 24 hours (Article 31).

3) Meanwhile, Article 23 of the former Emergency Medical Service Act provides that the standards for the payment of emergency medical service fees shall be determined by the Minister of Health and Welfare. Accordingly, the standards for the payment of emergency medical service fees (Article 2013-158 of the Ministry of Health and Welfare’s notification on October 11, 2013) provide that the standards for the payment of emergency medical service fees shall apply to cases where an emergency patient falling under Article 2 subparag. 1 of the Emergency Medical Service Act (hereinafter “emergency patient”) or a patient suffering from an emergency room is provided by a medical institution under Article 3 of the Medical Service Act (hereinafter “emergency patient”) (Article 2 subparag. 1(b)) (Article 2 subparag. 5 of the Emergency Medical Service Act), and that the standards for the calculation thereof shall apply to cases where an emergency medical institution under Article 2 subparag. 5 of the Emergency Medical Service Act provides that the patient himself/herself shall bear the full amount of the emergency medical service management fees in cases of a person who is not an emergency patient (hereinafter “non-emergency patient”).

C. Determination on the instant case

1) Examining the details and purport of the aforementioned relevant statutes in light of the relevant legal principles, insofar as the instant hospital provided first aid to emergency patients and non-emergency patients who were in the emergency room, it is difficult to view that the instant hospital’s emergency medical management fees received in relation to the first aid, etc. as the subject matter of unjust enrichment under Article 57(1) of the National Health Insurance Act, even if the instant hospital did not meet the “standards for Human Resources for Emergency Medical Services” at the time of providing first aid to emergency patients and non-emergency patients. Specific reasons are as follows.

(A) The purport of the Regulations on the Standards for Medical Care Benefits under National Health Insurance provides that “medical care institutions shall maintain adequate human resources, facilities, and equipment necessary for medical care benefits for policyholders, etc.” under the general principles of medical care benefits is to allow medical care institutions to provide appropriate medical care benefits to policyholders or their dependents, and it cannot be deemed that the number of persons exclusively in charge of emergency nurses working at local emergency medical institutions is to maintain above a certain level as stipulated in the former Emergency Medical Service Act.

(B) The purpose of the emergency medical management fee system is to restrain the internal source of non-emergency patients in an emergency room and resolve the overpopulatedness of the emergency room by imposing all emergency medical management fees on the patient in cases where the patient received first aid, etc. even though the patient is not an emergency patient. Furthermore, Article 2(2) Item (a) of the Emergency Medical Service Act provides that an institution capable of receiving emergency medical management fees shall be “emergency medical institutions under Article 2 subparag. 5 of the Emergency Medical Service Act” and it is difficult to deem that the emergency medical institution can receive emergency medical management fees only in cases where the emergency medical institution provided first aid, etc. under the conditions

(C) Article 35 of the former Emergency Medical Service Act (amended by Act No. 14329, Dec. 2, 2016) only stipulates that a designating authority may revoke the designation of an emergency medical institution if an emergency medical institution falls short of the designation standards. However, Article 35 of the Emergency Medical Service Act, which amended by Act No. 14329, provides that “The Minister of Health and Welfare, the Mayor/Do Governor, or the head of a Si/Gun/Gu, issued a corrective order to an emergency medical institution for a fixed period of time (Article 35(1)).” In such a case, the Minister of Health and Welfare, the Mayor/Do Governor, or the head of a Si/Gun/Gu, who issued a corrective order, may fully or partially suspend financial support until the corrective order is complied with (Article 3). If an emergency medical institution fails to comply with an order, the Minister of Health and Welfare may deduct the number of emergency medical treatment facilities for a fixed period of time until the emergency medical institution fails to meet the standards for taking into account regional emergency medical care institutions’s standard for health care.”

2) Nevertheless, the lower court determined that the instant hospital’s first aid management fees, etc. received by the instant hospital without meeting the “standards for human resources exclusively in charge of nurse services,” constituted “insurance benefits expenses received by continuous or other unlawful means” as the subject of unjust enrichment collection under Article 57(1) of the National Health Insurance Act. In so determining, the lower court erred by misapprehending the legal doctrine on the criteria for medical care benefits and the subject of unjust enrichment collection under the National Health Insurance Act, thereby adversely affecting

3. Conclusion

Therefore, without further proceeding to decide on the remaining grounds of appeal, the lower judgment is reversed, and the case is remanded to the lower court for further proceedings consistent with this Opinion. It is so decided as per Disposition by the assent of all participating Justices on the bench.

Justices Park Sang-ok (Presiding Justice)