2017Du36205 Revocation of Disposition to refund medical care benefit costs

A

Law Firm Tae, Attorneys Sung-sik et al., Counsel for the defendant-appellant

National Health Insurance Corporation

Attorney Park So-young, Counsel for the defendant-appellant

Seoul High Court Decision 2016Nu49701 Decided January 23, 2017

June 11, 2020

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

The grounds of appeal are examined.

1. Object of the disposition of unjust enrichment collection;

A. If medical care benefits were paid at a medical institution that was not lawfully established in violation of Article 33(2) of the Medical Service Act, the pertinent medical institution does not constitute a medical care institution that is entitled to claim medical care benefits under the National Health Insurance Act, and such medical care benefits cannot be included in the subject of medical care benefits under the National Health Insurance Act (see Supreme Court Decision 2014Da229399, May 29, 2015).

B. The lower court determined that D, other than medical personnel, established the instant member under the name of the Plaintiff around May 2009, led to the management of human and physical facilities, financial management, patient attraction, and distribution of profits from the instant member, and that the Plaintiff was employed by D during the pertinent period and was in charge of the patient treatment at the instant hospital. The lower court determined that the medical care benefit paid to the medical care institution established by non-medical personnel borrowed the name of the person qualified to establish the medical institution and opened the medical care institution constituted a disposition of unjust enrichment collection.

C. Examining the reasoning of the lower judgment in light of the record, the lower court did not err in its judgment 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.

2. Deserting or abusing discretionary power;

A. Article 57(1) of the National Health Insurance Act provides that "the Corporation shall collect all or part of the amount equivalent to the insurance benefits or the cost of insurance benefits from a person who has received the insurance benefits or a medical care institution who has received the insurance benefits costs by deceit or other fraudulent means," thereby clearly stating that it is possible to collect some of the amount. The above provision is intended to ensure the soundness of the finance for health insurance and medical benefits through the maintenance of a desirable benefit system by preventing the medical care institution from claiming the payment of the cost of benefits in an unjust manner (see Constitutional Court Order 2010Hun-Ba375, Jun. 30, 201). However, as a medical care institution for the collection of unjust enrichment results in the failure to redeem the cost of the medical care benefits already provided due to

Meanwhile, “the act of establishing a non-medical person’s medical institution” prohibited by Article 33(2) of the Medical Service Act refers to the act that a non-medical person primarily processes the recruitment and management of facilities and human resources of a medical institution, the report on establishment, the performance of medical business, the raising of necessary funds, the ownership of operational performance, etc. (see Supreme Court Decision 2018Do1079, Nov. 29, 2018). In other words, the founder, who is a medical person, only provides his/her name to the founder, does not participate in the establishment and operation of a medical institution, and only receives the remuneration for providing labor under his/her employment, and does not belong to the profits

In light of the contents of each provision of the above law, stay and legislative intent, and the legal nature of collecting unjust enrichment, it is reasonable to view that the collection of unjust enrichment under Article 57(1) of the National Health Insurance Act is an act of discretionary discretion. Furthermore, it is reasonable to deem that collecting the total amount of medical care benefit from a person who establishes and operates a medical institution without considering the medical care institution’s content and amount of medical care benefit costs, the role of the person who opens and operates the medical institution, the degree of illegality, the degree of accrual of the performance of the medical institution, the degree of profits the person who opens the medical institution acquired from the name of the founder, and the cooperation with the investigation, barring any other special circumstances, constitutes a violation of the principle of proportionality and an act of deviation from and abuse of discretion (see Supreme Court Decision 2015Du3996,

B. Nevertheless, without examining the above circumstances, the lower court determined that each of the instant dispositions, which collected the full amount of medical care benefit costs from the opening titleholder, did not violate the principle of proportionality or the principle of excessive prohibition. In so determining, the lower court erred by misapprehending the legal doctrine on the principle of proportionality and proportionality, and deviation and abuse of discretionary power, thereby adversely affecting the conclusion of the judgment. The Plaintiff’s ground of appeal assigning

3. Conclusion

Therefore, 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.

Supreme Court Decision 201

Justices Kim Jae-in

Justices Min Il-young in charge

Justices Lee Jae-hwan