Law Firm LLC, Attorneys Oh Chang-joon et al., Counsel for the defendant-appellant-appellant

Attorney Han-soo et al., Counsel for the plaintiff

1. Case summary

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

A. ○○○ Hospital (hereinafter “instant hospital”) which is a general hospital operated by the Plaintiff in 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 that the number of nurses exclusively in charge of emergency medical institutions should be at least five among the criteria for designation of regional emergency medical institutions (hereinafter referred to as “standards for human resources in exclusive charge of nurses in emergency room”), but thereafter, it has provided first aid and emergency medical services to patients, etc. who have continued to be in emergency room and received emergency medical treatment fees from the Defendant. The Defendant: (a) based on Article 57(1) of the former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter referred to as the “National Health Insurance Act”), based on Article 57(1) of the former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter referred to as “National Health Insurance Act”), the instant hospital collected emergency medical care management fees from the Plaintiff on December 29, 2016; and (b) the instant emergency medical care management fees (hereinafter referred to as “instant”).

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 on the prevention, diagnosis, and rehabilitation of diseases and injury, as well as on childbirth, death, and health promotion (Article 1). Therefore, the legislative purpose and regulatory subject of the Act are different from other individual administrative Acts, such as the Act on Emergency Medical Services. Therefore, whether the provision of medical care benefits and the receipt of medical care benefits by a medical care institution in violation of other individual administrative Acts, such as the Act on Emergency Medical Services, 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 taking into account the legislative purpose and purpose of the Act on National Health Insurance and other individual administrative Acts, taking into account the difference between the legislative purpose and regulatory subject thereof (see, e.g., Supreme Court Decisions 2017Du59284, Nov. 28, 2019; 209Du479, Mar. 19, 2007).

B. Details of the relevant statutes

1) Article 41(2) of the National Health Insurance Act provides that the criteria for the method, procedure, scope, upper limit, etc. 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 criteria and method for the application of health care benefit specified in attached Table 1, and [Attachment 1] subparagraph 1(d) provides that health care institutions shall maintain appropriate 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 the same) provides that, in principle, the head of a Si/Gun/Gu may designate a regional emergency medical institution among general hospitals under the Medical Service Act (Paragraph 1); and that matters necessary for designation standards for local emergency medical institutions shall be determined by Ordinance of the Ministry of Health and Welfare in consideration of Si/Gun/Gu’s demand for emergency medical services, supply, etc. (Paragraph 2). Accordingly, Article 18(1) [Attachment 8] of the Enforcement Rule of the Emergency Medical Service Act provides that “the standards for designation of regional emergency medical institutions shall be determined by the standards for facilities, human resources, and equipment of regional emergency medical institutions, so that the number of persons exclusively in charge of emergency medical services should be at least five persons, respectively. Furthermore, the former Emergency Medical Service Act maintains and operates facilities, human resources, equipment, etc. in accordance with the standards for designation of emergency medical institutions so that emergency medical institutions can treat 24 hours (Article 31-2).

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 (Ordinance No. 2013-158 of the Ministry of Health and Welfare on October 11, 2013) provide that the standards for the payment of emergency medical service fees shall apply to cases where an emergency medical institution provides medical treatment to an emergency patient falling under subparagraph 1 of Article 2 of the Emergency Medical Service Act (hereinafter referred to as "emergency patient") or a patient who is within an emergency room at a medical institution under Article 3 of the Medical Service Act (hereinafter referred to as "emergency patient") or an emergency room (Article 2 (1) (b) item (a)). As to the standards for the calculation thereof, an emergency medical service management fee calculated pursuant to subparagraph 5 of Article 2 of the Emergency Medical Service Act shall be paid to an emergency patient only on the first day of the first day, but in cases of non-emergency patient (hereinafter referred to as "non-emergency

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.

Even if the “standards for human resources in exclusive charge of nurses at the time” were not satisfied, it is difficult to deem that the instant hospital’s emergency medical management fees received in relation to the first aid, etc. fall under the “contributative fee” under Article 57(1) of the National Health Insurance Act, which is subject to the collection of unjust enrichment or other unfair means. Specific reasons are as follows.

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

(B) The purpose of the emergency medical management fee system is to restrain the internal source of non-emergency patients and resolve the over-populatedness of the emergency room by imposing all emergency medical management fees on the emergency patient in cases where the emergency room received first aid, etc. even though it does not correspond to an emergency patient. Furthermore, Article 2(2)(a) of the Emergency Medical Service Act provides that an institution capable of receiving emergency medical management fees shall be an emergency medical institution under Article 2(5) of the Emergency Medical Service Act. Thus, it is difficult to deem that the emergency medical management fee can be paid only when the emergency medical institution provided first aid, etc. while meeting all the criteria for designation of

(C) Article 35 of the former Emergency Medical Service Act (amended by Act No. 14329, Dec. 2, 2016); however, Article 35 of the Emergency Medical Service Act (amended by Act No. 14329) stipulates that the designation authority may revoke the designation of an emergency medical institution if an emergency medical institution falls short of the standards for designation. In such a case, the Minister of Health and Welfare, the Mayor/Do Governor, or the head of a Si/Gun/Gu has issued a corrective order to an emergency medical institution within a given 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, issued a corrective order to the emergency medical institution (Article 35(2)), may suspend all or part of financial support until the corrective order is complied with (Article 3).

In addition, if an emergency medical institution provides first aid to an emergency patient and non-emergency patient who was in the emergency room and received emergency medical service management fees, it is not desirable to collect the emergency medical service management fees received by the emergency medical institution as unjust enrichment pursuant to Article 57(1) of the National Health Insurance Act, even if the emergency medical institution fails to meet the standards for designation of the emergency medical institution at the time of providing first aid, etc. In addition, it is not desirable to collect the emergency medical service management fees received by the emergency medical institution as unjust enrichment pursuant to Article 57(1) of the National Health Insurance Act. A local emergency medical institution is an essential facility to protect the life and health of local residents. Therefore, even if a local emergency medical institution fails to meet the "standards for human resources in exclusive charge of emergency room" prescribed in attached Table 8 of the Enforcement Rule of the Emergency

In addition to the cancellation of designation of a local emergency medical institution or the imposition of fines for negligence, it is difficult to recognize that there is a need for public interest to punish emergency medical service management fees by considering them as illegal collection.

2) Nevertheless, the lower court determined that the instant hospital’s first aid and emergency medical service management fees, which were received by the instant hospital without meeting the “standards for human resources exclusively in charge of nurse services”, constituted “a continuous fee for insurance benefits received by other unlawful means and expenses for collection of unjust enrichment” 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 collection of unjust enrichment under the National Health Insurance

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 Noh Jeong-chul

Chief Justice Noh Jeong-hee

Justices Kim In-bok