[1] The method to determine 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 “the case where the payment of care benefits was made by fraud or other improper means” under Article 57(1) of the former National Health Insurance Act as the subject of unjust enrichment collection under Article 98(1)1 of the same Act and Article 28(1)1 of the Medical Care Assistance Act as the subject of business suspension

[2] In a case where the provisions of the former Regulations on the Establishment and Operation of Special Medical Equipment under the delegation by the Medical Service Act (excluding the part concerning the registration and inspection of quality control) are violated, whether the disposition of unjust enrichment collection under Article 57(1) of the former National Health Insurance Act or the disposition of business suspension under Article 98(1)1 of the same Act or Article 28(1)1 of the Medical Care Assistance Act is a ground for the disposition of business suspension (negative)

[3] In a case where Party A, who operates medical care and medical care institutions, did not perform overall control and supervision of the quality control of medical videos such as a computer-to-face photographing device, etc., for which Party B, etc. did not work in the actual medical care institution, and did not perform duties such as evaluation of video quality, and did not perform duties of remotely reading, and received medical care benefit and medical care benefit costs on the ground that Party A’s claim for medical care benefit and medical care benefit costs related to computer-to-face image diagnosis fees, the case holding that the lower court erred by misapprehending the legal doctrine, even though Party A’s claim for medical care benefit and medical care benefit costs cannot be deemed to constitute a case where Party A’s claim for medical care benefit and care benefit costs constituted “satisf or any other unfair means” as provided by Articles 57(1) and 98(1)1 of the former National Health Insurance Act and

[1] The former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter the same) 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, and rehabilitation of diseases and injuries, for childbirth and death, and for the improvement of social welfare. The Medical Care Assistance Act was enacted for the purpose of contributing to the improvement of public health and the improvement of social welfare by providing citizens with medical benefits to those who have difficulties in their lives. Therefore, the legislative purpose differs from that of other individual administrative laws, such as the Medical Service Act. Therefore, the provision of medical care benefits and medical benefits in violation of other individual administrative laws and the receipt of medical care benefits benefits should be determined by taking into account the need for administrative measures different from the legislative purpose of the National Health Insurance Act and other individual administrative measures, and the purpose of the provision of the Medical Care Assistance Act and the need for administrative measures under the National Health Insurance Act.

[2] The purport of the former Rules on the Standards for Medical Care Benefits in the National Health Insurance (amended by Ordinance of the Ministry of Health and Welfare No. 404, Jun. 3, 2016; hereinafter “Health Insurance Rules”) stipulating that “medical care institutions shall maintain adequate human resources, facilities, and equipment necessary for medical care benefits for subscribers, etc.” as the general principle for medical care benefits is to allow medical care institutions to provide medical care benefits for patients, and that “to register with certain human resources and facilities and undergo regular quality control inspections” in relation to special medical equipment is specified as the criteria for medical care benefits. Therefore, the remainder of the criteria for the recognition of installation and operation of special medical equipment under the delegation of the Medical Service Act (amended by Ordinance of the Ministry of Health and Welfare No. 613, Jan. 10, 2019; hereinafter “Health Insurance Rules”) excluding the part concerning the registration and quality control inspections can not be deemed as the grounds for business suspension under the Medical Service Act, regardless of whether it violates this, under Article 15(1)5(1)7) of the former National Health Insurance Act.

[3] In a case where Party A, who operates a medical care and medical institution, did not perform overall control and supervision of the quality control of medical videos such as a computer-to-face photographing device, etc., and did not work in a medical care institution, and received medical care benefit and medical care benefit costs on the ground that Party A reported it to non-speed personnel and received medical care benefit and expenses for computer-to-face image diagnosis fees, etc. on the ground that Party A received medical care benefit and medical care benefit costs, the case held that the lower court erred by misapprehending the legal doctrine, even if Party A claimed medical care benefit costs or medical care benefits for the computerized-to-story diagnostic fees, etc. using the computer-to-face photographing device registered as a quality control assessment assessment assessment through the video reading of a non-speed video medical specialist, the lower court erred by misapprehending the legal doctrine, which did not constitute “a continuous number or other unfair means” under Articles 57(1) and 98(1)1 of the former National Health Insurance Act (Amended by Act No. 13985, Feb. 3, 2016).

[1] Articles 57(1) and 98(1)1 of the former National Health Insurance Act (Amended by Act No. 13985, Feb. 3, 2016); Article 28(1)1 of the Medical Care Assistance Act / [2] Articles 57(1) and 98(1)1 of the former National Health Insurance Act (Amended by Act No. 13985, Feb. 3, 2016; Articles 7(2) and 28(1)1 of the Medical Care Assistance Act; Article 6(1) of the former Enforcement Rule of the Medical Care Assistance Act (Amended by Act No. 737, Jun. 29, 2020); Article 6(1) and 98(1)1 of the former Enforcement Rule of the National Health Insurance Act (Amended by Ordinance of the Ministry of Health and Welfare No. 404, Jun. 3, 2016); Article 5(1) [Attachment 1 and 6(1)3(d) of the former Medical Care Act]

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

Plaintiff (Law Firm LLC, Attorneys Hong Sung-l et al., Counsel for the plaintiff-appellant)

National Health Insurance Corporation and one other

Seoul High Court Decision 2019Nu50139, 50146 decided January 9, 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. Determination on the grounds of appeal Nos. 1 through 3

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, medical treatment, rehabilitation, childbirth, death, and 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 laws, such as the Medical Service Act, with the legislative purpose and subject of regulation (see Supreme Court Decision 2015Du36485, May 30, 2019). Therefore, the determination of whether providing medical care benefits and care benefits in violation of other individual administrative laws and receiving care benefits should be made based on the need for the collection of unjust enrichment under Article 57(1)1 of the National Health Insurance Act and Article 28(1)1 of the Medical Care Assistance Act, and the need for administrative and other administrative and medical care Assistance Act.

B. (1) Article 41(2) of the National Health Insurance Act provides that the standards, such as 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]. Article 41(1)1(d) of the same 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 Installation and Operation of Special Medical Equipment (amended by Ordinance of the Ministry of Health and Welfare No. 632, Oct. 13, 2019) provides that special health care institutions shall not be determined by the Governor.

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 the health of the people by providing for matters necessary for the public to benefit from high level of medical treatment (Article 1). In order to install and operate special medical equipment, it shall be registered with the head of a Si/Gun/Gu in compliance with the installation standards prescribed by Ordinance of the Ministry of Health and Welfare (Article 38(1)), and shall not undergo regular quality control inspections (Article 38(2)), and the special medical equipment determined inappropriate for quality control inspections shall not be used (Article 38(3)). The Medical Service Act’s regulations on special medical equipment under the delegation of Article 38(1) provides that the operation of the aforementioned special visual equipment shall not necessarily require more than one person with high-speed visual image processing than those with high-speed visual image processing (hereinafter referred to as “high-speed visual equipment, etc.”). According to Article 3(1) [Attachment 1] of the Medical Service Act, the Ministry of Health and Welfare’s regulations governing the installation of such equipment and its comprehensive control guidelines on medical treatment.

Furthermore, in cases where Article 38(1) and (2) of the Medical Service Act are violated by installing and operating special medical equipment in violation of Article 3(1) and (2) of the Regulations on Special Medical Equipment, the Medical Service Act 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 the correction of the violated matters (Article 63(1)). (Article 64(1)6, Article 67(1) and Article 38(3) provides criminal punishment in cases of violation of Article 8(3).

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 such as subscribers, 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 patients, and that the provision of “to have certain human resources and facilities registered and undergo regular quality control inspections” in relation to special medical equipment is specified as the criteria for medical care benefits. Therefore, the remainder of the criteria for the recognition of installation of special medical equipment under the Rules on Special Medical Equipment under the delegation of the Medical Service Act, excluding the aforementioned part of the criteria for the registration and quality control inspections, can not be deemed as a ground for the disposition of unjust enrichment collection under Article 57(1) of the National Health Insurance Act or the disposition of suspension of business under Article 98(1)1 of the National Health Insurance Act and Article 28(1)1 of the Medical Care Assistance Act, even if the aforementioned violation constitutes a ground for

Therefore, in a case where the Plaintiff claims for medical care costs or medical care costs for the video examination fees of the computerized group using a video recording device of the computerized group registered as a result of quality management assessment through the video reading by a non-exclusive video reading by a medical specialist, it cannot be deemed that the Plaintiff’s payment of medical care costs is a case where the Plaintiff received the medical care costs due to the “satisfy or any other unfair means” under Articles 57(1) and 98(1)1 of the National Health Insurance Act.

D. Nevertheless, the lower court determined that, on the basis of the circumstance that the Plaintiff’s non-exclusive film medical specialist did not work at a medical institution, the medical specialist was not in charge of overall control and supervision of the quality control of medical videos such as computerization team filming equipment, etc., and that the Plaintiff’s claim for medical care benefits and medical care expenses with respect to video diagnosis fees, etc., constitutes “cases where the costs of medical care benefits have been paid by fraud or other improper means” under Articles 57(1) and 98(1)1 of the National Health Insurance Act, Article 28(1)1 of the Medical Care Assistance Act, and Article 28(1)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 subjects

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 Lee Ki-taik (Presiding Justice)