2016Du41750 Revocation of Disposition to refund medical care benefit costs

1. A;

2. B

Plaintiffs 1. Law Firm ancientdo, Counsel for the plaintiff-appellant

Attorney Song-don, Justice Song-don, Justice Lee Don, Counsel for plaintiff-appellant;

Park Tae-tae, Alba-chan

2. Law firm green space;

Attorney Kim Jong-soo, Justice Kim Jong-sik, Justice Kim Jong-sik, Justice Park Jong-soo, and

3. Law firm reflect;

Attorney Lee In-bok, Lee Jong-soo, Kim Jong-sung, and Limit-type

National Health Insurance Corporation

Attorney Kim Han-soo, Counsel for the plaintiff-appellant

Seoul High Court Decision 2015Nu63816 Decided May 31, 2016

June 27, 2019

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 any statement in the supplemental appellate brief not timely filed).

1. As to the grounds of appeal Nos. 4, 5, 7, and 8

A. A. A person who has a qualification and license of a medical person established a medical institution pursuant to the Medical Service Act and provided health insurance policyholders or their dependents with health care benefits prescribed in the National Health Insurance Act. On the other hand, even if a medical person established and operated the medical institution under the name of another medical person, and thus violates Article 4(2) of the Medical Service Act, the medical institution is a medical care institution that can provide health care benefits under Article 42(1) of the National Health Insurance Act with only such circumstance.

The act of refusing to pay expenses for medical care benefits or receiving expenses for medical care benefits on the ground that the medical institution does not constitute “medical institution established” cannot recover the amount equivalent to the expenses for medical care benefits on the ground that the act of refusing to pay expenses for medical care benefits or receiving expenses for medical care benefits falls under “act of receiving expenses for medical care benefits by continuous or other unjust means” as prescribed by Article 57(1) of the National Health Insurance Act (see Supreme Court Decision 2016Du56370, May 30

B. Examining the reasoning and records of the lower judgment, the following facts are revealed.

(1) On November 1, 2011, Plaintiff A, an oriental medical doctor, claimed the Defendant for the costs of medical care benefits provided by “D Hospital” (hereinafter “instant hospital”) established under his/her name, and received KRW 238,254,820 from August 2, 2012 to June 13, 2013.

(2) On June 14, 2013, Plaintiff B, an oriental medical doctor, claimed the Defendant for the costs of medical care benefits provided by the instant hospital established under his/her name, and received KRW 401,690,300 from July 25, 2013 to August 26, 2014.

(3) On December 2, 2014, the Defendant rendered a disposition to recover KRW 238,254,820 of the medical care benefit cost to the Plaintiff and KRW 401,690,300 of the medical care benefit cost to the Plaintiff, on the ground that “E established and operated the instant hospital by lending the name of the Plaintiffs, and thereby violated Article 4(2) of the Medical Service Act.”

(4) An oriental medical doctor E bears the total amount of funds to establish the instant hospital, and is a person of the instant hospital.

The instant hospital was actually established and operated in the name of the plaintiffs, such as taking exclusive charge of the private company and financial management.

C. Examining the foregoing facts in accordance with the aforementioned legal principles, a physician, who is qualified and licensed as a medical practitioner, establishes the instant hospital under the name of a herb doctor, provided medical care benefits for the treatment, etc. of diseases to patients insured by health insurance or their dependents at the instant hospital, and received medical care benefits from the Defendant. As such, the instant hospital cannot recover the amount equivalent to the medical care benefits solely on the grounds that it is a medical institution established and operated by the instant hospital E by borrowing the Plaintiffs’ name.

D. Nevertheless, solely on the ground that Article 4(2) of the Medical Service Act was violated, the lower court determined that “the instant measure is lawful on the ground that the medical care benefit costs of the instant hospital did not fall under “medical institution established under the Medical Service Act, which is a medical care institution under the National Health Insurance Act,” or the medical care benefit costs received by the instant hospital are subject to restitution 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 restitution of unjust enrichment under Article 42(1)1 of the National Health Insurance Act and Article 57(1) of the same Act, thereby adversely

2. 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 Min Il-young

Chief Justice Cho Jae-hee

Justices Kim Jae-in

Justices Lee Jae-hwan