[1] The standard for determining whether the provision of medical care benefits and medical care benefits and the receipt of care benefits in violation of any other individual administrative law constitutes “a case where an insurer, etc. has been charged with care benefits by fraud or other improper means” under Article 98(1)1 and Article 99(1) of the former National Health Insurance Act and Article 28(1)1 and Article 29(1) of the Medical Care Assistance Act, which is subject to business suspension and imposition of penalty surcharges in lieu of business suspension

[2] In a case where the standard for approval of installation of special medical equipment (excluding the part concerning registration and inspection of quality control) prescribed by the former Regulations on the Establishment and Operation of Special Medical Equipment under the delegation of the Medical Service Act is violated, whether the provision of Article 98(1)1, Article 9(1) of the former National Health Insurance Act, Article 28(1)1, and Article 29(1) of the Medical Care Assistance Act constitutes grounds for business suspension and imposition of penalty surcharge in lieu of business suspension (negative)

[3] In a case where an administrative agency received a written confirmation from the investigating party to a specific offense during an on-site investigation, whether the value of the written confirmation may be denied (negative in principle)

[1] Articles 98(1)1 and 99(1) of the former National Health Insurance Act (Amended by Act No. 13985, Feb. 3, 2016); Articles 28(1)1 and 29(1) of the Medical Care Assistance Act / [2] Articles 98(1)1 and 99(1) of the former National Health Insurance Act (Amended by Act No. 13985, Feb. 3, 2016); Articles 26 of the Administrative Litigation Act / [3] Article 26 of the Administrative Litigation Act

[1] [2] Supreme Court Decision 2020Du3168, 31675 Decided July 9, 2020 (Gong2020Ha, 1614) / [1] Supreme Court Decision 2015Du36485 Decided May 30, 2019 (Gong2019Ha, 1310), Supreme Court Decision 2017Du59284 Decided November 28, 2019 (Gong20Sang, 189) / [3] Supreme Court Decision 2015Du2864 Decided July 11, 2017 (Gong2017Ha, 1630)

Medical Corporation, Busan Medical Foundation (Law Firm LLC, Attorneys Cho Jae-sik et al., Counsel for the defendant-appellant)

The Minister of Health and Welfare

Seoul High Court Decision 2019Nu49757 decided May 13, 2020

The judgment below is reversed and the case is remanded to Seoul High Court.

The grounds of appeal are examined (to the extent of supplement in case of supplemental appellate briefs not timely filed).

1. Whether grounds for appeal Nos. 1 and 2 are recognized (Ground of appeal Nos. 1 and 2)

A. The former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter “National Health Insurance Act”) was enacted with the aim 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 health. The Medical Care Assistance Act was enacted with the aim of contributing to the improvement of national health and the promotion of social welfare by providing citizens with medical benefits to those who have difficulties in their lives, and is distinguishable from other individual administrative Acts, such as the Medical Service Act, with the legislative purpose and subject to regulation (see Supreme Court Decision 2015Du36485, May 30, 2019). Therefore, the determination of whether the provision of medical care benefits and care benefits in violation of other individual administrative Acts and the receipt of care benefits ought to be made in consideration of the legislative purpose of Article 98(1)1 and Article 99(1)1 and Article 28(1)29 of the National Health Insurance Act as well as the need to impose individual benefit or penalty surcharge in lieu of the National Health Insurance Act.

B. (1) Article 41(2) of the National Health Insurance Act provides that the standards for 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 former Regulations on the Standards for Health Insurance Benefits (amended by Ordinance of the Ministry of Health and Welfare No. 404, Jun. 3, 2016; hereinafter “Rules on Health Insurance Benefits”) 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 specified in attached Table 1 [Attachment Table 1]. Subparagraph 1(d) of the above Rule provides that “medical care institutions shall maintain adequate human resources, facilities, and equipment necessary for health care benefits for subscribers, etc.” Article 38(1) of the Medical Service Act; Article 5(1) of the former Rules on the Establishment and Operation of Special Medical Equipment (amended by Ordinance of the Ministry of Health and Welfare No. 104, Oct. 13, 2019; Article 2(3) of the Special Self-Governing City Mayor or Metropolitan City Mayor.

Article 7(2) of the Medical Care Assistance Act and Article 6(1) of the former Enforcement Rule of the Medical Care Assistance Act (amended by Ordinance of the Ministry of Health and Welfare No. 737 of Jun. 29, 2020) provide that the standards and methods for applying medical care are in accordance with Article 5(2), (3), and attached Table 1 of the Health Insurance Benefit Rules.

(2) Meanwhile, the Medical Service Act was enacted for the purpose of protecting and improving citizens’ health by providing for matters necessary for the treatment of high-quality visual images for all citizens (Article 1); the installation and operation of special medical equipment in compliance with the installation standards prescribed by Ordinance of the Ministry of Health and Welfare (Article 38(1)); and shall undergo regular quality control inspections (Article 38(2)); and the special medical equipment determined inappropriate in quality control inspections shall not be used (Article 38(3) of the Medical Service Act. The aforementioned special medical equipment rules, supra, should have one or more professionals of non-speed visual image processing for the purpose of ensuring that all citizens can benefit from high-quality medical treatment (Article 38(1) [Attachment 1]; the Medical Service Act provides that the operation of such special medical equipment ought to be carried out by the competent medical institution for the purpose of monitoring and improving the quality of visual images; however, the Ministry of Health and Welfare’s installation and operation guidelines for non-exclusive medical treatment, which are no more than those of the foregoing special medical service regulations, but rather than those of the Ministry of Health and Welfare.

Furthermore, Article 38(1) and (2) of the Medical Service Act provides that where a person violates Article 38(1) and (2) of the Medical Service Act by installing and operating special medical equipment in violation of Article 3(1) and (2) of the Regulations on Special Medical Equipment, the Minister of Health and Welfare or the head of a Si/Gun/Gu may restrict or prohibit the use of all or part of the relevant facilities, equipment, etc. or order him/her to correct the violated matters (Article 63(1)). In addition, Article 64(1)6 and Article 67(1) of the Medical Service Act provides that an order to suspend or substitute for the order to suspend medical business, to revoke permission for establishment, and to close a medical institution may be issued (Article 8(1)1).

C. In light of the aforementioned legal principles and the contents of the relevant statutes, the purport of the Health Insurance Rule’s provision that “medical care institutions shall maintain adequate human resources, facilities, and equipment necessary for medical care benefits for the insured, etc.” as the general principle of medical care benefits is to allow medical care institutions to provide medical care benefits suitable for the treatment of the patient, and it can be deemed that the provision of “to have certain human resources and facilities registered and undergo regular quality control inspections” as the criteria for medical care benefits in relation to special medical equipment is specified as the criteria for medical care benefits. However, the remainder of the criteria for the recognition of installation of special medical equipment under the Rules on Special Medical Care under the delegation of the Medical Service Act, excluding the aforementioned ones for registration and quality control inspections, is subject to sanctions based on the Medical Service Act, notwithstanding its violation, it cannot be deemed as a ground for business suspension under Article 98(1)1 and Article 99(1) of the National Health Insurance Act or for the imposition of penalty surcharges in lieu thereof.

Therefore, insofar as it is appropriate to claim the insurer, etc. for medical care costs or medical care costs using the computerized group image examination equipment, which has been determined as appropriate for quality control through the video reading of the non-exclusive image medical specialist and has been registered as appropriate for claims for medical care costs or medical care costs, even if a medical specialist of the non-exclusive image department without attending a medical institution, this cannot be deemed as a case where the insurer, etc. was charged with medical care costs due to the "speed or any other improper means" under Articles 98(1)1 and 9(1) of the National Health Insurance Act, Articles 28(1)1 and 29(1) of the Medical Care Assistance Act (see Supreme Court Decision 2020Du3168, 31675, Jul. 9, 2020).

D. Nevertheless, the lower court determined that the circumstance that the Plaintiff’s non-exclusive film medical specialist did not work at a medical institution is based on the Plaintiff’s main reason and deemed that the above medical specialist did not perform duties, such as overall control and supervision of and evaluation of film quality of the equipment for the management of medical images of the computerization team. Furthermore, the lower court determined that the Plaintiff’s claim for medical care benefits and medical care benefits in relation to the video diagnosis fees of the computerization team constituted “cases where the insurer, etc. was charged with expenses by fraud or other improper means” as prescribed in Articles 98(1)1 and 9(1)1 of the National Health Insurance Act, Articles 28(1)1 and 29(1) of the Medical Care Assistance Act. In so determining, the lower court erred by misapprehending the legal doctrine on the criteria for medical care benefits and medical care benefits as prescribed in the National Health Insurance Act and the Medical Care Assistance Act and the subject of penalty surcharges

2. Whether grounds for appeal No. 2 are acknowledged (Ground of appeal No. 3)

A. Unless special circumstances exist, such as where an administrative agency has obtained a written confirmation from the other party to an investigation to a specific offense in the course of conducting an on-site investigation, the value of the written confirmation cannot be easily denied, barring special circumstances, such as that the written confirmation is forced against the will of the originator, or it is difficult to take the written confirmation as evidentiary materials for specific facts due to lack of details (see Supreme Court Decision 2015Du2864, Jul. 11, 2017, etc.).

B. The lower court determined that, comprehensively taking account of relevant evidence, such as the Plaintiff’s representative Nonparty 1 and Nonparty 2’s written confirmation from the head of the planning office of the hospital in the course of the on-site investigation with respect to the instant hospital, the lower court determined that Nonparty 3, who is not qualified as a water treatment physician, provided the patient with a stratotory treatment at the ○ Hospital from July 2013 to September 2014 during the investigation period, could recognize the fact that the Plaintiff received the medical care benefit

C. Examining the relevant legal principles and records, the lower judgment did not err by exceeding the bounds of the principle of free evaluation of evidence against logical and empirical rules, contrary to what is alleged in the grounds of appeal.

3. Conclusion

Therefore, without further proceeding to decide on the remainder of the 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

Justices Kim Jae-hyung (Presiding Justice)