[1] Where a medical care institution makes a request for review to the Health Insurance Review and Assessment Service to claim medical care benefit costs against the National Health Insurance Corporation, the burden of proving that the medical care benefit satisfies the criteria for health care benefit under the laws and regulations such as the law

[2] The legal nature of the criteria or guidelines for review of medical care benefits determined by the president of the Health and Welfare Review and Assessment Service after deliberation by the Health and Welfare Review Committee (hereinafter “Criteria for review and payment of medical care benefits”) pursuant to the notification of the Minister of Health and Welfare (hereinafter “Criteria for review and payment of health care benefit costs”), and whether such criteria can be considered

[1] The appropriate medical care benefit that can be paid is limited to cases where it conforms to the criteria for recognition prescribed by statutes, and even if the Health Insurance Review and Assessment Service (hereinafter “Review and Assessment Service”) imposed a disposition that recognizes only part of the costs claimed by the health care institution as appropriate medical care benefit because it is contrary to the legal standards, it is only meaningful to confirm the scope of appropriate medical care benefit not to limit or reduce the claim for medical care benefit already held by the health care institution, but to confirm the appropriate scope of the health care benefit. Therefore, where a health care institution makes a request for review to the National Health Insurance Corporation (insurer) in order to claim for medical care benefit,

[2] The guidelines for review or examination of medical care benefits determined by the president of the Health Insurance Review and Assessment Service (hereinafter “Review and Assessment Service”) after deliberation by the Medical Care Review Committee (hereinafter “Criteria for Review and Payment of Medical Care Benefit Costs”) is merely an internal work process standard prepared by the Review and Assessment Service to apply the criteria for recognition of medical care benefits under the Acts and subordinate statutes to specific medical treatment, and does not necessarily constitute an appropriate medical care benefits recognized under the Acts and subordinate statutes, on the ground that the criteria do not meet the administrative rules. However, unless there are special circumstances to deem that the criteria are objectively unreasonable in light of the purpose or purport of the National Health Insurance Act, such criteria are considered as the detailed criteria for determining the appropriateness of medical care benefits

[1] Articles 39 (see current Article 41), 43 (2) (see current Article 47 (2)), and 47 (7) (see current Article 47 (7)) of the former National Health Insurance Act (Amended by Act No. 7347, Jan. 27, 2005); Articles 12 (see current Article 19), and 13 (see current Article 20) of the former Enforcement Rule of the National Health Insurance Act (Amended by Act No. 314, Apr. 22, 2005); Article 43 (2) and (7) of the former National Health Insurance Act (Amended by Act No. 7347, Jan. 27, 2005; see current Article 47 (2)); Article 47 (7) of the former Enforcement Rule of the National Health Insurance Act (Amended by Act No. 7347, Apr. 21, 2005; see current Article 313 (3) of the former Enforcement Rule of the National Health Insurance Act)

[1] Supreme Court en banc Decision 2010Du27639 Decided June 18, 2012 (Gong2012Ha, 1312)

Plaintiff (Law Firm Sejong, Attorneys Kim Jong-soo et al., Counsel for the plaintiff-appellant)

Health Insurance Review and Assessment Service (Law Firm Gyeong, Attorneys Noh Jeong-soo et al., Counsel for the defendant-appellant)

Gwangju High Court Decision 2007Nu565 decided October 30, 2008

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

The grounds of appeal are also examined.

1. According to various Acts and subordinate statutes governing national health insurance (in this case, Article 39(2) and (3) of the former National Health Insurance Act, except as otherwise expressly provided for in Acts and subordinate statutes, all medical care benefits are included in the subject of health care benefit. Specific standards, methods, and procedures for health care benefit are prescribed by the Ordinance of the Ministry of Health and Welfare ("Rules on the Standards for Health Insurance Benefits") and the Ministry of Health and Welfare’s announcement ("Detailed Rules on the Standards and Methods of Health Care Benefits." Therefore, health care institutions are provided with health care benefit in accordance with the standards and procedures prescribed in the Act on the Standards for the Recognition of Health Care Benefits unless legal non-benefit medical care benefits are provided. In addition, even if the insurer and the insured receive health care benefit from the insurer, etc., they should comply with the criteria and procedure for the calculation thereof (see Supreme Court en banc Decision 2010Du27639, 27646, Jun. 18, 2012).

Meanwhile, the criteria for review or examination of medical care benefits determined by the president of the Review and Assessment Service following the review of the Medical Care Benefit Review Committee pursuant to the notice of the Minister of Health and Welfare ("Criteria for review and payment of medical care benefit costs") are internal business guidelines prepared by the Review and Assessment Service to apply the criteria for recognition of medical care benefits prescribed by the Acts and subordinate statutes to specific medical treatment, and merely does not necessarily constitute an appropriate medical care benefits recognized by the Acts and subordinate statutes, on the ground that they do not meet such criteria. However, barring any special circumstance to deem that the criteria are objectively unreasonable in light of the purpose or purport of the National Health Insurance Act and the National Health Insurance Act, such criteria

2. The court below decided to the effect that, among the medical care benefit costs of this case requested by the plaintiff, it is not sufficient or not sufficient to prove that all or part of spine surgery and materials for medical treatment that the defendant did not recognize the propriety thereof (excluding the parts saved in the appeal procedure against the defendant or the examination procedure of the Health Insurance Dispute Mediation Committee) constitutes an appropriate medical care benefits for paying the medical care benefits in accordance with the medical care benefits standards prescribed by the above notice. The court below's findings of fact and determination are justified, and there are no errors in the misapprehension of legal principles as to the criteria for determining the reasonableness of medical care benefits or the burden of proof under the national health

Other grounds of appeal are merely criticisming the fact-finding that belongs to the lower court’s discretion and cannot be accepted.

3. Therefore, the Plaintiff’s appeal is dismissed, and 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 Kim Chang-suk (Presiding Justice)