The plaintiff's remaining appeals are dismissed.

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. in accordance with the standards and procedures prescribed by 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), and when the insurer, the insured, etc. receive the health care benefit from the insurer, etc., the medical care institution shall not only provide the health care benefit to the subscribers, etc. in accordance with the criteria and procedures prescribed by the statutes on the criteria for recognition of health care benefit, but also include not only the expenses that the Defendant must notify to the subscribers, etc. under Article 43-2(1) and (2) of the former National Health Insurance Act, but also the expenses that the insured, etc. received at will without complying with the criteria and procedure.

However, even in cases where a medical care institution conducts non-benefit medical treatment outside the framework of the National Health Insurance Act and receives the relevant expenses from the subscribers, etc., under the circumstances where there is no procedure, such as (i) the relevant Acts and subordinate statutes implemented at the time of such medical treatment, which is included in the scope of the National Health Insurance Act as a medical care benefit subject or non-benefit subject to medical care benefits or can reasonably adjust the relevant medical care benefit costs; or (ii) the procedure is not deemed to have been avoided in light of the details and urgency of the non-benefit medical treatment, as well as the relevant procedure’s required time and the process, etc., in light of such specific circumstances as the content and urgency, the procedure is difficult to deem to have been avoided. (iii) If the medical care institution has already been provided with sufficient explanation to the subscribers, etc. about the medical care benefit subject to the medical care benefit recognition standard, it shall not be deemed to have been excessive for the expenses received in return for such medical treatment (see, e.g., Supreme Court en banc Decision 2010Du27646, Jun.

Here, the consent of a policyholder, etc. expresses his/her intent to waive the entitlement to national health insurance and to have his/her entire medical expenses borne by the policyholder, etc., and the medical care institution provides information necessary for the policyholder, etc. to determine whether to give consent thereto. Therefore, the content of the relevant medical care act, the medical care institution’s explanation to the policyholder, etc. is not subject to medical care benefits, and the medical necessity and the approximate cost to be borne by the policyholder, etc. should be included in the medical care institution.

Whether a medical care institution has sufficiently explained and consented to the requirements to deem that the cost does not constitute an excessive personal burden even where the medical care institution conducts voluntary non-benefit treatment and received the cost from an insured person, etc. should be determined depending on whether the entitlement to a policyholder, etc. and the right to a voluntary non-benefit treatment can be deemed substantially guaranteed in light of all the circumstances, including the content of the aforementioned explanation and the urgency of the medical care and the degree of explanation. In addition, such legal doctrine likewise applies to cases where a medical care institution is expected to repeat multiple non-benefit treatment in connection with a specific disease or treatment act in the future, and where the medical care institution explains and approves the aforementioned matters with regard to multiple non-benefit treatment to the insured, etc. at once (see, e.g., Supreme Court Decision 2013Du2208, Mar. 24, 2016).

B. The reasoning of the lower judgment and the evidence duly admitted reveal the following facts.

(1) G hospital operated by the Plaintiff (hereinafter referred to as the “Plaintiff hospital”) and its affiliated father-cell organ transplant center are blood-related specialized treatment institutions, such as leuk transfusions.

(2) The organ transplant transplant is currently recognized as the only treatment method for patients suffering from blood diseases, such as leukosis, and it is recognized as the only treatment method for treating patients suffering from disease, such as the current leukosis. < Amended by Act No. 1010, Jan. 1, 201; Act No. 1010, Mar. 1, 201; Act No. 1010, Mar. 2, 2011; Act No. 10211, Mar. 2, 2011>

As such, it seems practically impossible to explain in advance all non-benefit medicines or materials for medical treatment, etc. individually and obtain prior consent for each medical treatment because the treatment period is long-term, and there is a need for immediate treatment when a merger or infection occurs at each stage.

(3) From 2004 to 2006, the Intervenor was hospitalized in the Plaintiff hospital and was hospitalized in the Defendant’s auxiliary intervenor who was suffering from acute leuklogal tymosis, and received related medical treatment.

At the time of the Intervenor’s hospitalization, the Intervenor’s spouse prepared a written agreement of hospitalization stating that “if an emergency operation or inspection is necessary during the hospitalization, the treatment performed without his/her guardian’s prior consent (including non-benefit items that are excluded from those subject to national health insurance benefits and are necessary for the diagnosis and treatment) shall not raise any objection to the treatment” and submitted it to the Plaintiff hospital.

(4) After that, the Intervenor’s spouse provided a sufficient explanation to the effect that there may arise the benefit limitation that is not recognized in the health insurance benefit period even if it was approved as a protoma cell transplantation, and the benefit limitation portion was written out and submitted to the Plaintiff hospital, including that “the Intervenor’s spouse shall raise an objection at the total cost of the insured (patient) and shall consent to the notarial act without raising an objection.”

(5) Accordingly, for the treatment of the Intervenor who received the surgery on the transplantation of the protoma cell, the part on the “separate in calculating the cost of materials, equipment, etc.” as indicated in the judgment of the court below based on the above hospitalization agreement, the application for transplant of the protoma cell, etc. (the medical care benefit cost is already included in the medical care benefit cost standard, and thus it cannot be separately calculated, but the cost of materials, equipment, etc. for medical treatment or equipment, etc. was separately collected from the relevant winners) and the part on the medication other than the permitted matters (the Plaintiff hospital violated the medical care benefit standard on the efficacy, effect, usage, and dosage, etc. of the medicine and collected the cost of the medicine to the relevant winners). In light of the aforementioned legal principles, even if the written admission agreement and the application for transplant prepared by the Intervenor’s spouse in advance without reference to the content and necessity of individual non-benefit treatment, there is sufficient explanation to what extent the consent was given in relation to the treatment and treatment in this case as well as to what extent that the consent was actually given.

If so, the court below erred by misapprehending the legal principles as seen earlier.

After a detailed deliberation on the circumstances, etc., it should have determined whether sufficient explanation and consent related to the voluntary non-benefit treatment of this case were given based on the results of the deliberation. However, on the erroneous premise that it is difficult to deem that the preparation of a comprehensive written consent without conducting a deliberation on such part is sufficient explanation and consent to the voluntary non-benefit treatment of this case, it is difficult to deem that the Plaintiff’s sufficient explanation and consent was given to the Plaintiff’s hospital regarding the voluntary non-benefit treatment of this case. Thus, the Plaintiff’s claim seeking revocation of the disposition in this case was dismissed. In so determining, the lower court erred by misapprehending the legal doctrine on the method and degree of explanation and consent regarding the voluntary non-benefit treatment of this case, thereby failing to exhaust all necessary deliberation, which affected the conclusion of the judgment. The allegation contained in the grounds of appeal assigning this error is with merit.

2. The appeal concerning "the part concerning the settlement of benefits" is examined.

The plaintiff is entitled to claim for medical care benefit costs under the Medical Care Benefit Standard, among the judgment below.

The plaintiff hospital filed an appeal against the remaining National Health Insurance Corporation, which is likely to reduce the costs of health care benefit to be claimed from the winners of the medical care benefit to be claimed, in light of the past review cases. However, there is no indication in the grounds of appeal as to the petition of appeal and the grounds of appeal.

Conclusion

Therefore, the part of the judgment of the court below concerning the "non-calculated portion" and "the non-permitted part concerning medication other than permitted matters" is reversed, and that part of the case is remanded to the court below for further proceedings consistent with this Opinion. The remaining appeal by the plaintiff is dismissed. It is so decided as per Disposition by the assent of all participating Justices on the bench.

Justices Lee In-bok

Justices Kim Gin-young

Chief Justice Lee Dong-won