[1] The method to determine whether the provision of medical care benefits and the receipt of medical care benefits in violation of other individual administrative laws such as the Medical Service Act constitutes “the case of receiving the insurance benefits costs by continuous or other unjust means” as the subject of unjust enrichment collection under Article 57(1) of the former National Health Insurance Act

[2] Whether the act of receiving the pertinent medical care benefit cost constitutes “the act of receiving the medical care benefit cost by means of continuous or other unjust means” solely on the ground that the medical care benefit was provided in excess of the number of hospitalization rooms of a psychiatrist under the former Mental Health Act and subordinate statutes (negative)

[1] The former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter the same) was enacted for the purpose of providing citizens with insurance benefits for the prevention, diagnosis, and rehabilitation of diseases and injuries, for childbirth and death, and for the improvement of social security by providing citizens with insurance benefits for the prevention of and rehabilitation from diseases and injuries, and for the improvement of social security, and differs from other individual administrative laws, such as the Medical Service Act, etc. Therefore, whether the provision of medical care benefits and the receipt of medical care benefits in violation of other individual administrative laws, such as the Medical Service Act, constitutes a case where the provision of medical care benefits and the receipt of medical care benefits was made by fraud or other improper means, should be determined by taking into account the legislative purpose and purpose of the former National Health Insurance Act and other individual administrative laws, taking into account the difference between the legislative purpose and subject matter of regulation under the National Health Insurance Act and other individual administrative laws.

[2] The general principle of medical care benefits under the Rules on the Standards for Medical Care Benefits in the National Health Insurance Act provides that “A medical care institution shall maintain adequate human resources, facilities, and equipment necessary for medical care benefits for policyholders, etc.” is to require a medical care institution to provide appropriate medical care benefits to policyholders or their dependents, and it cannot be deemed that it is intended to restrict and maintain the number of hospital rooms of a psychiatrist under the former Mental Health Act (wholly amended by Act No. 14224, May 29, 2016; hereinafter the same shall apply) and the former Enforcement Rule of the Mental Health Act (wholly amended by the Enforcement Rule of the Act on the Improvement of Mental Health and the Support for Welfare Services for Mental Patients, No. 497, May 30, 2017). In addition, even if a mental medical institution violates facility standards under the former Mental Health Act and subordinate statutes, it is difficult to recognize that medical care benefits are subject to sanctions under the former National Health Insurance Act, unless it falls short of or exceeds the standards for medical care benefits prescribed under the National Health Insurance Act.

Therefore, solely on the fact that a medical care benefit was provided in excess of the number of hospitalization rooms of a psychiatrist under the former Mental Health Act and subordinate statutes, the act of receiving the relevant medical care benefit does not constitute “the act of receiving the medical care benefit benefits by means of continuous or other unjust means.”

[1] Article 57 (1) of the former National Health Insurance Act (Amended by Act No. 13985, Feb. 3, 2016) / [2] Article 41 (2) (see current Article 41 (3)) of the former National Health Insurance Act (Amended by Act No. 13985, Feb. 3, 2016); Article 5 (1) [Attachment 1] subparagraph 1 (d) of the Regulations on the Standards for Medical Care Benefits for National Health Insurance; Article 1 (see current Article 1 of the Act on the Improvement of Mental Health and the Support for Welfare Services for Mental Patients) of the former Mental Health Act (Amended by Act No. 1424, May 29, 2016); Article 12 (1) (see current Article 19 (1) of the Mental Health Improvement and the Support for Welfare Services for Mental Patients); Article 41 (3) of the former Enforcement Rule of the Mental Health Act (Amended by Act No. 13985, Feb. 3, 20197>

[1] Supreme Court Decision 2015Du36485 Decided May 30, 2019 (Gong2019Ha, 1310), Supreme Court Decision 2017Du59284 Decided November 28, 2019 (Gong2020Sang, 189)

Plaintiff (Law Firm Ba, Attorneys Lee In-hwa et al., Counsel for the plaintiff-appellant)

National Health Insurance Corporation

Seoul High Court Decision 2018Nu63404 decided March 28, 2019

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

The grounds of appeal are examined.

1. As to the assertion that there is no ground for disposition of unjust enrichment collection

A. The former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter “National Health Insurance Act”) was enacted for the purpose of contributing to the improvement of national health and the improvement of social security by providing citizens with insurance benefits for the prevention, diagnosis, medical treatment, and rehabilitation of diseases and injuries, for childbirth and death, and for the promotion of health (hereinafter “National Health Insurance Act”). Accordingly, other individual administrative Acts, such as the Medical Service Act, are different from their legislative purpose and subject matter of regulation (see Supreme Court Decision 2015Du36485, May 30, 201). Therefore, whether the provision of medical care benefits and the receipt of medical care benefits in violation of other individual administrative Acts, such as the Medical Service Act, constitutes a case where “the cost of insurance benefits was paid by fraud or other improper means” under Article 57(1) of the National Health Insurance Act should be determined by taking into account the difference between the legislative purpose and subject matter of regulation under the National Health Insurance Act and the National Health Insurance Act’s legislative purpose and other administrative laws.

B. Article 41(2) of the National Health Insurance Act provides that the criteria for the method, procedure, scope, upper limit, etc. of health care benefit shall be prescribed by Ordinance of the Ministry of Health and Welfare. Accordingly, Article 5(1) of the Regulations on the Standards for Medical Care Benefits under National Health Insurance provides that health care institutions shall provide health care benefit for the insured, etc. according to the criteria and method for the application of health care benefit under attached Table 1, and [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 benefit for the insured, etc.

Meanwhile, Article 12(1) of the former Mental Health Act (wholly amended by Act No. 14224, May 29, 2016; hereinafter the same) provides for necessary matters concerning the prevention of mental illness and the medical treatment and rehabilitation of mentally ill persons (Article 1) to contribute to the improvement of citizens’ mental health (Article 1); the standards for facilities and equipment of mental medical institutions; the number of employees, including medical personnel, and the number of and qualifications for mental medical institutions (Article 12(1)). Following delegation, Article 7(1) [Attachment 2] of the former Enforcement Rule of the Mental Health Act (wholly amended by the Enforcement Rule of the Act on the Improvement of Mental Health and the Support for Welfare Services for Mental Patients (wholly amended by Ordinance of the Ministry of Health and Welfare, No. 497, May 30, 2017; hereinafter the same shall apply) provides that “A mental hospital may order a person who has been hospitalized with at least 50 patients” in the part of the facility standards, and a mental medical institution shall be ordered to suspend or install facilities within the scope of one year.

C. Examining the contents and purport of the relevant statutes based on the aforementioned legal doctrine, the purport of the Regulation on the Standards for Medical Care Benefits under the National Health Insurance Act that provides that “medical care institutions shall maintain adequate human resources, facilities, and equipment necessary for medical care benefits such as policyholders, etc.” as the general principle of medical care benefits is not to require medical care institutions to provide appropriate medical care benefits to the insured or their dependents, nor to restrict and maintain the number of wards in a psychiatrist under the former Mental Health Act and subordinate statutes. In addition, even if a mental medical institution violates facility standards under the former Mental Health Act and subordinate statutes, it is difficult to recognize that there is a need for public interest to punish the medical care benefits paid to the relevant mental medical institution as the subject of unjust enrichment collection under the National Health Insurance Act, unless it falls short of the medical care benefits standards under the National Health Insurance Act or exceeds the said standards.

Therefore, solely on the fact that a medical care benefit was provided in excess of the number of hospitalization rooms of a psychiatrist under the former Mental Health Act and subordinate statutes, the act of receiving the relevant medical care benefit does not constitute “the act of receiving the medical care benefit benefits by means of continuous or other unjust means.”

D. Nevertheless, the lower court determined that the medical care benefits provided to more than 49 patients from among the inpatients of the instant council members constituted “cases where the costs of insurance benefits have been paid in a continuous or other unjust manner” as the subject of unjust enrichment collection under Article 57(1) of the National Health Insurance Act. In so determining, the lower court erred by misapprehending the legal doctrine on the criteria for medical care benefits and the subject of unjust enrichment collection under the National Health Insurance Act,

2. Conclusion

Therefore, without further proceeding to decide on the remaining grounds of appeal, 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

Justices Park Sang-ok (Presiding Justice)