Government Legal Service Corporation (Law Firm LLC)

Attorney Choi Jong-chul et al.

1. Case summary and key issues

A. According to the reasoning of the original judgment and the record, the following circumstances are revealed. (1) Plaintiff (hereinafter “Plaintiff”) is a doctor who opened and operated ○○○○○○○ Medical Center (hereinafter “Korea Council member”) in Sungnam City ( Address omitted). (2) Plaintiff (hereinafter “Plaintiff”) received medical care benefits from the Service in the instant case for a period from July 1, 2013 to December 31, 2013, in fact from part of the patients during the instant Medical Council members: (1) the National Health Insurance Non-Support Act or Non-Supportary Correction Act, and (2) the medical care benefits for the instant case was provided only to some patients; (3) the medical care benefits for the instant case was provided (4) the health care benefits for the instant case (hereinafter “the instant medical care benefits costs”).

(3) On May 2, 2017, the Defendant: (a) on the ground that the instant violation constitutes “a case where the Plaintiff was charged with the costs of medical care benefits by continuous acceptance or other improper means”; (b) pursuant to Article 98(1)1 of the former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter the same shall apply), Article 70(1) [Attachment 5] of the former Enforcement Decree of the National Health Insurance Act (amended by Presidential Decree No. 2743, Aug. 2, 2016; hereinafter the same shall apply) on the ground that the instant violation constitutes “where the Plaintiff was charged with the costs of medical care benefits”; and (c) pursuant to the criteria for the suspension of business and the imposition of penalty surcharges.

145 Japan's medical care institution's business suspension disposition was made (hereinafter referred to as "instant disposition").

B. In light of the fact that the instant violation constitutes a ground for disposition under Article 98(1)1 of the former National Health Insurance Act, the Plaintiff also does not dispute. The key issue of the instant case is whether the instant violation constitutes a case where the instant violation constitutes a case where the instant violation uses a "speedd number" as a circumstance to be considered in the context of disposition under Article 70(1) [Attachment Table 5] of the former Enforcement Decree of the National Health Insurance Act and the criteria for the disposition of suspension of business and the imposition of penalty surcharges.

2. Relevant regulations and legal principles

A. In general, sanctions are imposed on the objective facts that constitute a violation of administrative laws and regulations to achieve administrative purposes. Inasmuch as such sanctions are imposed on a person, other than a realistic actor, who is stipulated as a person in charge under laws and subordinate statutes, and barring special circumstances, such as where a person cannot be found to have breached his/her duties, it may be imposed on the offender even if he/she did not have any intention or negligence (see, e.g., Supreme Court Decision 201Du873, May 11, 2017). (ii) Even if an administrative agency’s determination of sanctions was made on the basis of the foregoing facts, it is difficult to readily conclude that there was an abuse of discretionary authority’s discretionary authority’s burden of proof based on the following facts: (a) if the administrative agency did not have any discretion to prove that there was an abuse of discretionary authority’s discretion; or (b) if the administrative agency did not have any reason to prove that there was a deviation or abuse of discretionary authority’s discretionary authority’s discretion, it should be considered that there was an abuse of discretionary authority.

B. (1) Article 98(1)1 and (5) of the former Enforcement Decree of the National Health Insurance Act provides that the Minister of Health and Welfare may order a medical care institution to suspend its business for a fixed period of not more than one year, and the criteria for administrative disposition based on the type and degree of violation against which the suspension of business is imposed and other necessary matters shall be prescribed by Presidential Decree. According to Article 70(1) [Attachment Table 5] of the former Enforcement Decree of the National Health Insurance Act, the term “standards for the suspension of business and the imposition of penalty surcharge” is not prescribed in Article 98(1)1 and (5) of the former Act. Article 98(1)1 and (5) of the former Enforcement Decree of the National Health Insurance Act provides that the insurer shall not be subject to the imposition of monthly average unreasonable amount and the period of suspension of business based on unfair rates, and Article 98(1)2 of the former Enforcement Decree of the National Health Insurance Act provides that the insurer shall not be subject to the reduction or exemption of medical care benefit costs by taking into account the motive, degree and frequency of violations.

Therefore, in order to suspend business pursuant to Article 98(1)1 of the former National Health Insurance Act, an administrative agency is sufficient to prove the objective circumstance that a certain medical treatment act claimed and received by a medical care institution is not payable as a medical care benefit cost according to the National Health Insurance Act and subordinate regulations (see, e.g., Supreme Court en banc Decision 2010Du27639- 27646, Jun. 18, 2012). The relevant medical care institution did not use the term “speed number”. The circumstance is that it is considered at the disposal stage of an administrative agency and the court’s review of the deviation and abuse of discretion. Thus, the Plaintiff’s assertion as favorable circumstances ought to be proven. (2) In such a case, “act” means a medical care institution’s fraudulent act that did not receive medical care benefit cost in compliance with the insurance Act and subordinate regulations, such as a method of deceiving the public health care institution or providing documents related to the medical care benefit cost, such as a fraudulent treatment act, without being aware of the medical care benefit cost.

The issue of whether a medical care institution was aware of the fact that it cannot be paid as expenses for medical care benefits under the National Health Insurance Act and subordinate statutes and regulations thereof is not determined on the basis of only the founder of the medical care institution. If a medical care institution’s act, such as filing a request for medical care benefits or preparing relevant documents, including medical care records, was conducted by an agent or employee, etc., the determination should be made on the basis that all relevant persons, including an agent, etc. (see Supreme Court Decision 2016Du36079, Jul. 27, 2016). (3) The main medical care act of a medical care institution constitutes “non-eligible items” as prescribed by Article 9(1) [Attachment Table 2] of the Regulations on the Standards for Payment of National Health Insurance Benefits under the delegation of Article 41(3) of the former National Health Insurance Act, constitutes an act of medical care institution, including examination, examination, and treatment, conducted before and after the medical care institution incidental to the medical care act, and thus, it cannot be determined on the basis of the determination.

3. Judgment on the instant case

가. 앞서 본 사실 관계, 제1심판결 및 원심판결의 이유와 기록에 의하여 알 수 있는 다음 과 같은 사정 들을 이러한 법리에 비추어 살펴보면, 원고가 이 사건 한의원에서 실제 시술 되지 않은 진료행위가 이루어진 것처럼 진료기록부 를 허위로 작성하였기 때문에 그에 기초 하여 실제와 다른 내용으로 요양급여비용 청구가 이루어진 것으로 보이고 , 따라서 이 사건위반행위는 원고가 '속임수'를 사용하여 공단에 요양급여비용을 부담 하게 한 경우 로 볼여지가 크다. ( 1 ) 원고 는 , i ) 종전에는 이 사건한의원에서환자들에게 ① 국민건강 보험 비급여 대상인 ' 비강 내치 요법 ' 이나 '추나삼차원교정술'(이하 통틀어 '제1진료행위'라고 한다)을 시술 하면서 그 전 · 후에환자들의 염증과 긴장을 완화하여 제1진료행위의 치료효과를 더욱 높이기 위하여 ② '유침법'(침 을 시술하고 일정 시간 유지한 후 제거하는 침법) 의일종 인 침술 ( 경혈 침술-2부위 이상, 척추간 침술, 침전기 자극술 등)과 온냉경락요법- 경피 적외선 조사 요법 등(이하 통틀어 '제2진료행위'라고 한다)을 시술하였으나, ii) 2013. 7. 1. 부터 2013. 12.31.까지의 기간 동안에는 제 1진료행위의 전 ·후에 ③ 사혈침, 소아침 과 같은 ' 행 침법 ' ( 침을 이용하여 반복적으로 경혈을 자극하는 침법, 이하 통틀어 '제 3진료 행위 ' 라고 한다 )을 시술하는 것으로 시술방법을 변경하였는데, 요양급여비용 청구업무 를 담당 하는 직원(간호사)이 시술방법 변경의 의미를 이해하지 못하고 종전처럼제 2 진료 행위 가 이루어진 것으로 오해하여 제2진료행위에 관하여 요양급여비용을 청구하는 입력 작업 을 함에 따라 단순 착오로 부당청구가 이루어진 것일 뿐이라고 주장한다. 그러나 이러한 주장은 다음과 같은 이유에서 그대로 믿기 어렵다. ( 2 ) 이러한 원고 의주장에 의하더라도, 2013.7.1.부터 2013.12.31.까지의 기간 동안에 이 사건 한의원에서 비급여대상인 제 1진료행위에 부수하여 제3진료행위가 이루어졌을 뿐 , 제 2 진료 행위는 이루어진 바 없다. 그런데도 원고는 수기(手記) 진료기록부 에는 제 1 진료 행위 만 기록한 반면, 전자 진료기록부에는 제2진료행위가 이루어진 것처럼 허위 로 기재 하였다.원고는 2015.10. 23. 이 사건 한의원에 대한 현지조사 과정에서 ' 전자 진료 기록부 에요양급여비용 청구가 가능한 내역으로 원고 본인이 입력하였음' 을자인 하는 내용 의 사실확인서(갑 제6호증의 1)를 작성하였는데, 그 내용을 믿기 어렵다.고 볼 만한 특별한 사정이 없다. ( 3 ) 전자 진료 기록부 자체가 원고에 의해서 허위로 작성된 것이라면, 이 사건 한의원의 직원 이 실제 이루어진 바 없는 제3진료행위에 관하여요양급여비용을 청구하는 내용 으로 입력 작업 을한 것은, 해당 직원이 단순한 부주의나 착오 때문이 아니라 이미 허위 로 작성된 전자진료기록부대로 입력작업을 하였기때문으로 보인다. ( 4 ) 위와 같은 원고의 주장을 그대로 믿더라도, 제3진료행위는 비급여대상인 제1진료 행위 에 부수 하여 이루어진 것이라고 보아야 하므로, 제3진료행위도 비급여대상에 해당하여 요양 급여 비용 을청구하는 것이 허용되지 않는 경우에해당한다. 그런데 원고 는 제 3진료행위가 제1진료행위와 병행하여 이루어졌을 뿐, 제1진료행위와 별개 의 독립적 인요양급여 제공행위에 해당한다고 주장하고 있다. 만약 진료행위 당시에 원고 스스로가 제3진료행위가 제1진료행위와 별개의 독립적인 요양급여제공행 위에 해당 하는 것으로 인식하였다면, 수기 진료기록부나 전자 진료기록부 중 어느 한쪽에 는 제 3 진료 행위가 이루어진 사실을 '있는 그대로 진실하게' 기재하는 것이 자연스럽고 , 그렇게 한 경우에는 다른 진료기록부에 실제 진료행위와 다른 내용이 일부 기재되어 있다고 하더라도 이는 단순한 부주의나 착오 때문이라고 선해할 여지도 있다. 그러나 원고 는 요양 급여비용 청구서 입력과정에서 담당직원의 부주의나 착오를 탓할 뿐, 정작 본인 이 굳이 양쪽 진료기록부 모두에 진실한 사실과 다르게 기재한 이유에 관하여 납득할 만한 설명을 제시하지 못하고 있다. 오히려 원고가 제3진료행위를 수기 진료 기록부 나 전자 진료기록부에 기재하지 않은 것은, 실제 제3진료행위가 이루어지지 않았 거나 또는 제 3 진료행위가 이루어졌다고 하더라도 제3진료행위가 요양급여비용을 청구 할 수 있는 대상이 아니라는 점 을 스스로 인식하고 있었기 때문이라고 보인다.

B. Nevertheless, the lower court, solely based on its stated reasoning, determined that the instant violation was caused by an employee’s mistake, and cannot be deemed to be a case where the Plaintiff used a “speed” due to the use of a fraudulent act, and determined that the instant disposition taken place on the premise that the Plaintiff used a fraudulent act and made an unfair claim by the use of the deceptive act was a deviation or abuse of discretionary power, without considering all the grounds for mitigation. In so determining, the lower court erred by failing to exhaust all necessary deliberations by misapprehending the legal doctrine on the unfair claim of medical care benefit costs under the National Health Insurance Act, thereby failing to exhaust all necessary deliberations, or by exceeding the bounds of free conviction due to logical and empirical rules, which affected the conclusion of the judgment. The grounds for appeal pointing this out are with merit.

4. Conclusion

Therefore, the judgment of the court below is reversed, and the case is remanded to the court below for a new trial and determination. It is so decided as per Disposition by the assent of all participating Justices on the bench.

Justices Park Sang-ok

Justices Noh Jeong-hee

Justices Kim Jae-hwan of the District Court