In cases where a policyholder, etc. of national health insurance receives medical care benefits without filing an application for medical care benefits under the National Health Insurance Act, such as receiving medical care benefits under the National Health Insurance Act, whether the National Health Insurance Corporation is obligated to provide the policyholder, etc. with medical care benefits (negative), and in such cases, whether the National Health Insurance Corporation should return the medical care benefits to the insured, etc. in unjust enrichment solely on the ground that the medical care institution would have been able to receive medical care benefits from

The national health insurance system is a social insurance system that copes with social risks, such as illness and injury, arising to the people with the financial resources of the insurance premium paid by the insured and the national treasury burden (Article 3 subparagraph 2 of the Framework Act on Social Security). Therefore, the requirements for receiving national health insurance benefits, the scope of beneficiaries, and the amount of benefits, etc. are specifically formed and determined by law.

Medical care benefits under the National Health Insurance Act are, in principle, benefits in kind are provided in principle, so insurance benefits are practically provided when the insured receives medical care from a medical care institution.

However, there is an exception to the principle of spot benefit as above. Where a policyholder, etc., who performs a function similar to a medical care institution due to urgency or other inevitable reasons prescribed by Ordinance of the Ministry of Health and Welfare, receives medical care for a disease, injury, childbirth, etc. from an institution prescribed by Ordinance of the Ministry of Health and Welfare or gives birth at a place other than a medical care institution, the National Health Insurance Corporation shall pay the amount equivalent to medical care benefits

As such, in order for the insured, etc. of the National Health Insurance to receive medical care benefits, it is necessary to apply for medical care benefits to a medical care institution, unless exceptionally meeting the requirements for claiming medical care benefits pursuant to Article 49(1) of the National Health Insurance Act. If benefits in the form of spot benefit through a medical care institution are provided upon the application of medical care benefits by the insured, the National Health Insurance Corporation only bears medical care benefits for

Where a third party’s act causes insurance benefits to be provided to an insured person, etc., the National Health Insurance Corporation shall obtain a claim for damages from a third party to the extent of expenses incurred in paying benefits (Article 58(1) of the National Health Insurance Act). In cases where the amount of compensation for damages arising from the exercise of the National Health Insurance Corporation’s right to indemnity is determined by a court’s judgment, etc. in relation to school safety accidents under Article 58 of the National Health Insurance Act, the amount to be borne by the principal of a school shall be borne by the School Safety Mutual Aid Association (proviso of Article 36(2) of the Act on the Prevention of and Compensation for School Safety Accidents). The Korea Workers’ Compensation and Welfare Corporation recognizes that the payment decision is revoked after the payment of health care benefits to an insured person under the Industrial Accident Compensation Insurance Act, and that the Korea Workers’ Compensation and Welfare Corporation is equivalent to health

However, there is no provision that insurance companies or subscribers, etc. may claim ex post facto the National Health Insurance Corporation to pay the amount equivalent to the costs of health care benefit when the policyholders, etc. receive the benefit of automobile insurance without receiving the benefit of health insurance.

In light of the regulatory structure and content of the National Health Insurance Act, which differs from those of the other provisions regarding the procedures for and reimbursement of health care benefit, as seen above, in light of the National Health Insurance Act, a policyholder, etc. who wishes to receive health care benefit under the National Health Insurance Act shall file an application for health care benefit with a health care institution by submitting a health insurance card, etc. Where a policyholder, etc. receives medical care benefit without filing an application for health care benefit under the National Health Insurance Act, such as receiving medical care benefit under the National Health Insurance Act, etc., the National Health Insurance Corporation is not obligated to provide any health care benefit to the policyholder, etc.. In such a case, even if a health care institution had received medical care

Article 3 subparag. 2 of the Framework Act on Social Security; Articles 12(2), 41(1), 44(1), 47(1) and (2), and (3), 49(1), 58(1), and 61 of the National Health Insurance Act; Articles 3(1) and 90(2) of the Regulations on Medical Care Benefits for National Health Insurance; Articles 41(1) and 90(2) of the Industrial Accident Compensation Insurance Act; Articles 21(1) of the Enforcement Rule of the Industrial Accident Compensation Insurance Act; Article 36(1) and (2) of the Act on the Prevention of and Compensation for School Safety Accidents; Article 741 of the Civil Act

Supreme Court Decision 2012Da39103 Decided September 13, 2012

Plaintiff (Attorney Kim Jae-sik, Counsel for plaintiff-appellant)

National Health Insurance Corporation (Attorney Cho Jae-ho, Counsel for defendant-appellant)

Seoul Western District Court Decision 2016Na31057 decided September 8, 2016

The appeal is dismissed. The costs of appeal are assessed against the plaintiff.

The grounds of appeal are examined.

1. A. The national health insurance system is a social insurance system that copes with social risks, such as illness and injury, arising to the people from the financial resources of the insured’s insurance premiums and the national treasury’s burden (Article 3 subparag. 2 of the Framework Act on Social Security). Therefore, specific requirements for the supply of and demand for national health insurance benefits, the scope of beneficiaries, the amount of benefits, etc., are specifically formed and determined

B. (1) Medical care benefits under the National Health Insurance Act are, in principle, benefits in kind are provided in kind, and insurance benefits are practically provided when the insured was treated in a medical care institution (see Supreme Court Decision 2012Da39103, Sept. 13, 2012, etc.).

The National Health Insurance Act, etc. provides detailed procedures for providing health care benefit. A policyholder or his/her dependent who intends to receive health care benefit (hereinafter “subscriber, etc.”) shall file an application for health care benefit with a health care institution (Article 12(2) of the National Health Insurance Act, and Article 3(1) of the Regulations on the Standards for Health Care Benefit in National Health Insurance). A health care institution in receipt of an application for health care benefit may request the National Health Insurance Corporation to pay the health care benefit after providing the insured, etc. with health care benefit, such as diagnosis, examination, provision of medicine and materials, treatment, surgery, and other medical treatment, preventive and rehabilitation, hospitalization, nursing, and transfer, and then the health care institution that intends to claim the health care benefit (Articles 41(1) and 47(1) and (2) of the National Health Insurance Act). Upon receiving a notice of examination from the Health Insurance Review and Assessment Service, the National Health Insurance Corporation shall immediately pay the health care benefit to the health care institution in accordance with the content thereof (Article 47(3) of the National Health Insurance Act).

However, there is an exception to the principle of spot benefit as above. Where a policyholder, etc. receives medical care for a disease, injury, childbirth, etc. from an institution prescribed by Ordinance of the Ministry of Health and Welfare, which performs a function similar to a medical care institution due to urgency or other inevitable reasons prescribed by Ordinance of the Ministry of Health and Welfare, or gives birth to a person other than a medical care institution, the National Health Insurance Corporation shall pay the amount equivalent to the medical care benefit

As such, in order for the insured, etc. of the National Health Insurance to receive medical care benefits, it is necessary to apply for medical care benefits to a medical care institution, unless exceptionally meeting the requirements for claiming medical care benefits pursuant to Article 49(1) of the National Health Insurance Act. If benefits in the form of spot benefit through a medical care institution are provided upon the application of medical care benefits by the insured, the National Health Insurance Corporation only bears medical care benefits for

(1) A person who intends to receive medical care benefits shall apply for medical care benefits to the Korea Workers’ Compensation and Welfare Service (Article 41(1) of the Industrial Accident Compensation Insurance Act). Upon receipt of an application for medical care benefits, the Korea Workers’ Compensation and Welfare Service, upon receipt of an application for medical care benefits, shall decide whether to pay the medical care benefits and notify the applicant and the insured thereof (Article 21(1) of the Enforcement Rule of the Industrial Accident Compensation Insurance Act). Therefore, a beneficiary shall directly file a claim for medical care benefits with the Korea Workers’ Compensation and Welfare Service, which is not a medical care institution, and upon the request of the beneficiary, the Korea Workers’ Compensation and Welfare Service determines to pay the benefits (see, e.g., Supreme Court Decision 2009Da9847, Feb. 25, 2010). 2) In the case of school safety mutual aid (see, e., Supreme Court Decision 2009Da98447, Feb. 25, 2010).

(2) Where the National Health Insurance Corporation provides insurance benefits to an insured person, etc. due to a third party’s act, it shall obtain a right to claim compensation for damage from such third party to the extent of expenses incurred in paying such benefits (Article 58(1) of the National Health Insurance Act). Where the amount of compensation for damage arising from the exercise of the National Health Insurance Corporation’s right to indemnity under Article 58 of the National Health Insurance Act is determined by a court’s judgment, etc. in relation to school safety accidents, the principal of a school shall bear the burden of the School Safety Mutual Aid Association (proviso of Article 36(2) of the National Health Insurance Act). Where the Korea Workers’ Compensation and Welfare Corporation paid medical care benefits to an insured person under the Industrial Accident Compensation Insurance Act and the decision on payment thereof is revoked, and it is recognized that the payment thereof is equivalent to the health care benefits, etc. that can be paid pursuant to the

However, there is no provision that insurance companies or subscribers, etc. may claim ex post facto the National Health Insurance Corporation to pay the amount equivalent to the costs of health care benefit when the policyholders, etc. receive the benefit of automobile insurance without receiving the benefit of health insurance.

C. In light of the regulatory structure and content of the National Health Insurance Act, which differs from those of the other provisions regarding the procedures for, and reimbursement of, medical care benefits, as seen above, in light of the relationship between the National Health Insurance Act and the National Health Insurance Act, a policyholder, etc. who wishes to receive medical care benefits as a national health insurance shall file an application for medical care benefits by submitting the health insurance card with a medical care institution. In such a case, if a policyholder, etc. received medical care benefits without filing an application for medical care benefits under the National Health Insurance Act, such as receiving medical care benefits under the National Health Insurance Act, the National Health Insurance Corporation is not obligated to provide any medical care benefits to the policyholder, etc.. In such a case, even

2. A. The reasoning of the lower judgment reveals the following facts.

The Plaintiff initially received medical treatment due to automobile insurance and paid medical expenses, etc. to the medical institution that treated the Plaintiff by Hyundai Marine Fire Insurance Co., Ltd. (hereinafter “Modern Marine Fire”) (hereinafter “Modern Marine Fire”). It was revealed that the Plaintiff could not receive medical treatment due to automobile insurance through a trial, thereby returning all medical expenses, etc. to Hyundai Marine Fire.

The Plaintiff asserted in the instant lawsuit as follows. The Plaintiff was practically treated as a general medical treatment by returning insurance proceeds to Hyundai Marine Fire. Defendant Corporation is obligated to return the medical care benefit cost as unjust enrichment, or pay the medical care cost equivalent to the medical care benefit cost pursuant to Article 49(1) of the National Health Insurance Act, as the Plaintiff was exempted from the medical care benefit cost that the Defendant Corporation would have incurred if the Plaintiff had been treated as the health insurance.

B. In light of the following circumstances, the lower court rejected the Plaintiff’s claim for return of unjust enrichment on the ground that the Defendant Corporation cannot be deemed to have made unjust enrichment or to have an obligation to return the amount to the Plaintiff. ① The medical expenses of modern marine fire paid to the medical institution, which were returned by the Plaintiff, cannot be deemed as the medical expenses calculated for motor vehicle insurance medical fees under the Guarantee of Automobile Accident Compensation Act, and the payment standards for which are different, cannot be recognized as the amount of medical care benefits under the National Health Insurance Act, and cannot be determined through a review of propriety of the Health Insurance Review and Assessment Service, so it cannot be readily concluded that Defendant Corporation exempted the payment of the above amount. ② The Plaintiff is entitled to claim for spot care benefits, such as medical treatment,

Next, the lower court rejected the Plaintiff’s claim for payment of medical care expenses on the ground that the Plaintiff cannot be deemed to fall under an institution prescribed by Ordinance of the Ministry of Health and Welfare, which performs similar functions as a medical care institution, and that it cannot be deemed to fall

C. The lower court’s determination is based on the legal doctrine as seen earlier. In so doing, it did not err by misapprehending the legal doctrine on medical care benefits and medical care expenses under the National Health Insurance Act.

3. The Plaintiff’s appeal is dismissed as it is without merit. The costs of appeal are assessed against the losing party. It is so decided as per Disposition by the assent of all participating Justices on the bench.

Justices Lee Dong-won (Presiding Justice)