206Nu16382. Revocation of revocation of the reduction of insurance benefit cost.

Medical Corporation, 000 Foundation

Yeongdeungpo-gu Seoul Metropolitan Government Yeongdeungpo-dong 000

Representative Director 000

Law Firm Doz.

Health Review Service

Seocho-gu Seoul Metropolitan Government Seocho 3 Dong 1586 - 7

Representative, Director Kim Chang-chul

Law Firm Doz.

Litigation Performers;

Seoul Administrative Court Decision 2004Guhap40747 decided June 28, 2006

September 20, 2007

November 8, 2007

1. Revocation of a judgment of the first instance;

2. The plaintiff's claim is dismissed.

3. All the costs of lawsuit shall be borne by the Plaintiff in the first and second instances.

1. Purport of claim

On June 1, 2003, the Defendant’s reduction disposition regarding KRW 2,299,040,040, the insurance benefit cost of △△△△△, which was paid to the Plaintiff.

The reduction disposition on KRW 6,288,725 of the insurance benefit cost of the Sector and Dog terms shall be revoked, respectively.

2. Purport of appeal

The order is as set forth in the text.

1. Details of the disposition;

A. The Plaintiff is a corporation running a hospital of 0000 located in Gangdong-gu Seoul Metropolitan Government 000, which is a national health corporation.

Medical institutions that provide medical care benefits under the Insurance Act, and the defendant are the medical care benefits expenses under the National Health Insurance Act.

It is the representative of a corporation that evaluates the appropriateness of medical care benefits and examination.

B. The Plaintiff provided medical care benefits for △△△ and △△△, as described below (1) and (2):

Defendant as the medical care benefit cost of △△△△△, KRW 9,038, KRW 410, and KRW 9,400,7

With respect to 00 won, each request for review of medical care benefit costs was made.

(1) On November 7, 2002, 000 hospitals are △△△△△△, hospitalized on the right side of 000.

(1939. (2) - 3 - 4 - 5 - the vertebron flion in the 1939.0

on November 13, 2002 - 3- 4, 4, 5 , 5 , - 5 vertebrates in the 1,00s, 5 - vertebrates in the 1,00s, and 5 e.g.

C - 1,000 vertebrates (ped currew) eight, Roddd (rod) after implementing the 1,000 conical laps.

Two used 2 - 3 - 4 - 5 vertebrate cryptism.

(2) (2) 000 hospitals are OO(2) hospitalized on December 4, 2002 'the right side of 1938'.

S. 2 - 3 - - 4 Madropolytic pressure and vertebrate so as to examine the results of the examination for the following:

December 9, 2002 - Nos. 1 - 2 - 3 - 4 - 5 Hashes after performing vertebrecin verteculum and pelaculum in 4 verteculum.

In the trend, 10 vertebrates and 2 vertebrates were carried out.

C. Upon examining the Plaintiff’s above medical care benefit costs, the Defendant’s medical care benefit costs are assessed against △△△△△△△.

vertebrate brates, 8 vertebrates, 2 Rod, and vertebrates, among vertebrates performed

Modles 10 vertebrates, vertebrate cliff, brate clifin clifin clifin clifin clifin clifin clifin

2 The grounds that there is no ground to recognize usefulness, such as there is no symptoms for which each procedure has been conducted.

On June 1, 2003, the amount of KRW 4,903,255 out of the medical care benefit costs of △△△△△△△ shall be reduced, and the medical care benefit costs of △△△△△.

Among them, 6, 936, 263 won was reduced.

D. The Plaintiff filed an objection against the above disposition on June 26, 2003, and the Defendant filed an objection against △△△△△.

Of the amount of objections, four invertebal brates and two inverte 2,581, 920 won for two medical care benefit costs.

The remainder was dismissed.

E. The plaintiff filed a request for review on December 10, 2003, and the Health Insurance Dispute Mediation Committee made a request for review on September 21, 2004.

The Defendant recognized Maebrecinary ebrate (including anesthesia and material ebrate on July 9, 2004)

622, 116 won) The portion shall be dismissed on the ground that it was 622, 116 won, and the remainder shall be dismissed.

was made.

F. Accordingly, the amount reduced by the Defendant in relation to the instant case is 8,587,765 won in total, and among them, △△△△.

Part on the medical care benefit costs of △△, 2, 299, 040 won, and part on the medical care benefit costs of △△△△

This 6, 288, 775 won (the above-mentioned reduction disposition on June 1, 2003, recognized as above and remaining reduction disposition

Part of the Disposition in this case is 'the Disposition in this case').

[Ground of Recognition] Unstrifed Facts, Gap evidence 1, Gap evidence 2, Gap evidence 3-1 to 4, Gap evidence 4

1-1 through 3, entry of Eul evidence 5, the purport of the whole pleadings

2. Whether the instant disposition is lawful

A. Party’s assertion

(1) The plaintiff's assertion

For the following reasons, as to the △△△△△, which is a medical institution belonging to the Plaintiff, 000 hospital

The disposition of this case which was found to be appropriate for each of the above operations

illegal.

1. In the case of △△△△△, the 2-3 main pages, 4-5 main pages and 5 main pages in terms of simple radiation opinions - 1

The interval of side signboards between the trends shows narrow views, and Nos. 2 - 2-3 are side signboards.

이른바 넛슨 ( knutsson ) 현상이 동반되고 있었으며 , 특히 제4 - 5 요추간은 불안정으로 인

There was an opinion on verteball vertebrate, and Nos. 2-3, 3, 3-4, 4-5 of the vertebrate Embrates

It was observed from the 1,000 to the 5th century - the 1,000 vertebrate so far.

The above hospital shall conduct 3-4 - The vertebrate inverte inverte and sphere inverte so that it may reduce the pressure by conducting vertebrates and sphere

Corresponding inverte in order to maintain the pressure effect through the use of a device (inverte)

지 유합술 ) 을 시행하였으며 , 특히 제2 - 3 요추간에는 넛슨현상을 동반한 척추관협착증

at the same time treatment is to prevent the unstableness that may be caused in the future. In this case, vertebrate colonism

There is no sufficient duplicating effect of pressure with spine cupincule and conical signboard removal only.

In addition, it is necessary to fully expand the vertebrate and the vertebrain colon through finites.

치료의 원칙이고 , 이미 척추간의 간격이 좁아져 있고 넛슨현상을 보이는 제2 - 3요추간

The treatment of vertebrate convergence was reasonable.

(2) In the case of terms and conditions, 3 - 4 pressures on the side of the main text and main text and main text, and pressures on the 2, 3, and 4 main text and text.

It was shown that there was a serious dynasty inverte as well as inverte flive opinions.

- 3- The vertebrate vertecopic vertebrates due to the external transition of the 4th century shall be reduced by vertebrate vertecule and verteth

After attempting to pressure, the vertebrates using the device were tried to implement the vertebrates, but the above patient was to do so.

In addition to the general opinion of Madio Madio Nos. 3-4, it is shown that the pressure between the 3-4 Madio Madio

Section 2 of this Section is inevitable to combine with other parts of this Section. In the event of vertebrate ebrate using an instrument ebrate, ebrate ebrate ebrate

The principle of medical treatment is to extend the scope of the agreement, in the event that, inter alia, pressure divers are accompanied.

(2) The defendant's assertion

As seen below, the part of the cut △△△ and Magna Mag Magna is involved in the above procedure

It is medically unreasonable in light of the standards for medical care benefits and the general principles of medical care.

Therefore, the above disposition is lawful.

(1) In the case of △△△△△, 4-5 Sponsor shall be identified on the vertebrates, the frontline of which is verified.

It is reasonable to implement but between 2 - 3, 3- - 4 Eentral ebrates (vental)

indentation ; 움푹 들어감 ) 은 있었지만 , 전 , 후방 및 사위에서 명확한 척추관 협착증으

It is not visible from the external side booms, and the opinion of the court on the surface of the front line and the front line (lithsys).

It is not clear so that a wide range of tensions through spine livers can be seen as inevitable.

Therefore, 2-3, 3- - 4 vertebrates used in vertebrates shall have different grounds to recognize.

not identified.

2. In the case of terms and conditions, it appears that there is a pressure to see otherwise, in the case of terms and conditions, 2 - 3 - 4 Hasheted, but acute frame.

The pressure rate of Section 2 is less than 40 per cent, and the opinion of vertebrate colonis is not clear and is not clear;

3- 4 Outwards cannot be seen as having a serious degree of external power failure, and the gap between disks is narrow.

There is no 1 - 2 Hashes, Nos. 2-3 , 3- 4 , 4-5 vertebrates in the verteculs

(2) If there is no or no knife knife knife knife knife knife

There is no other confirmed reason to recognize the fixedness of the charge.

B. Key issue of the instant case

Therefore, the issues of the instant case are as follows: (a) 2-3 conjections and 3-4 conjections against △△△△△△△.

The four inverteballs and four inverteballs, and all inverteballs and ebrates used in Geball Doz.

Aftermathly, balging, in light of the standards for medical care benefits and the general principles of medical care;

It is called whether proper treatment was given or not.

3. Determination

(a) Relevant statutes;

As shown in the attached Form.

(b) Scope of medical care benefits in national health insurance;

(1) The discretion and limitations of the doctor's treatment

If it is deemed that there is no negligence as a result of the diagnosis of a doctor's disease, any applicable law shall prevail.

Whether or not to take action shall be the case of the patient's own and its own professional expertise based on the patient's status.

shall be determined by knowledge and experience, and some of the measures to think shall be decided by will.

that is reasonable as a measure to be taken, the discretion of the doctor in question to determine what is the

to the extent of this section, only one of them is justified and any other measure is taken.

all of them shall not be deemed to be negligent (Supreme Court Decision 98Da45379 delivered on March 26, 199).

See Decision ).

However, the discretion of treatment has a certain limit for the following reasons.

First, from the internal point of view of reasonableness of medical treatment itself, the doctor's method of medical treatment or the preference of medicine

Where the propriety and rationality are clearly lack in the process of care at home and post, the discretion of medical care shall be given.

It should be viewed as a deviation (see Supreme Court Decision 84Meu1881 delivered on October 28, 1986).

At this time, in judging the propriety of medical practice, the seriousness of the disease and natural progress, etc.

(1) the effect of the treatment performed, the expenses incidental thereto, and the degree of risk, shall be compared and bridgeed.

. Then, in terms of the external aspect of promoting public welfare, only resources shall be limited.

by ensuring the soundness of finance in the national health insurance system operated; and

The most economical and cost-effective treatment method should be selected to do so.

(c)in other words, health insurance is prevention, diagnosis, medical treatment, rehabilitation, childbirth and death of a citizen's disease or injury;

The improvement of national health and the certificate of social security by providing insurance benefits for health promotion;

The purpose of this policy is to promote, and the payment of medical care benefit costs is based on the insured's insurance premiums.

Since it is composed of improper health care benefit costs, it is due to the payment of health care benefit costs.

Damage or damage caused by the patient as well as the general public who ultimately pays the insurance premium.

Rules on the criteria for medical care benefits in national health insurance and national health insurance that cannot be derived at the expense of the people;

B. that the detailed content is enacted by specific delegation of the National Health Insurance Act, a superior corporation.

Comprehensively taking account of various circumstances such as the recognition of medical care benefits, policy statements taking into account financial factors in the recognition of medical care benefits.

However, the Minister of Health and Welfare shall take into account such circumstances as the National Health Insurance cannot be avoided.

Enforcement Rule of the same Act established upon delegation by the Act, and the standard for national health insurance benefits

Rule: 'Rules'; 'Rules for Review and Payment of Medical Care Benefits'; 'Standards and methods for the application of Medical Care Benefits';

Only the medical care benefits recognized in the 'Supplementary Matters' can be paid for the expenses.

(2) Medical burden of proof

Articles 43(2), 39(2) and (3), and 42 of the National Health Insurance Act, and regulations on the enforcement of the same Act

Articles 12(1) and 13(1) of the Regulations apply to the defendant in order for a medical care institution to receive medical care benefit costs.

the disease, the date of commencement of medical care, the number of days of medical care, the contents of medical care benefit costs, the prescription, etc.

A request for examination of medical care benefit costs shall be made by entering the details requested for examination into medical care benefit standards, etc.

The Corporation shall examine whether the examination and decision are appropriate and notify the Health Insurance Corporation and the health care institution thereof.

under the provision that medical care benefit costs shall be paid to the relevant medical care institution according to the defendant's review and determination

(2) the Corporation.

In full view of the aforementioned relevant laws and regulations, the medical care institution may provide specific medical care benefits to the defendant.

In filing a claim for examination of expenses, the medical care benefits shall be the standard and method for applying the medical care benefits.

on the other hand, clearly explaining that it falls under any item of the criteria for recognition set forth in the same section;

The medical burden of proof is that the medical care benefit satisfies the requirements of the item.

In particular, since the information on medical practice becomes an exclusive part of the medical institution, medical practice is treated as a medical practice.

The agency should present medical grounds for the appropriateness and effects of the diagnosis and treatment.

Therefore, the Plaintiff, who operates a medical institution, is deemed to have received medical records and inspection data through the medical records and inspection data.

The treatment for the patients of this case shall be economical on the basis of an accurate diagnosis by the best method;

as well as appropriate medical care benefits provided in the National Health Insurance Act and effective

Recognition prescribed in the detailed rules on standards or the standards and methods for applying medical care benefits;

The fact that the standards are met shall be attested.

(3) Standard for examining medical care benefit costs

(A) Medical care established by the Minister of Health and Welfare on the basis of delegation under section 13(5) of the Enforcement Rule of the Act.

According to Article 4 of the Guidelines for Examination and Payment of Expenses for Benefits, the defendant shall pay medical care benefits at the time of request for examination.

Defendant in addition to the criteria prescribed by the rules concerning medical care benefit costs prescribed by the Minister of Health and Welfare.

The director shall meet the criteria for review of medical care benefit costs determined after deliberation by the Medical Treatment Review Committee.

of this case among the criteria for the examination of medical care benefit costs of the defendant

Part above is as follows, and this is a detailed letter of the criteria and method for applying the above medical care benefits.

Paragraph 1, 2003, prior to the repeal by disclosure of the review guidelines.

(B) vertebrate ebrates using vertebrates (including apparatus, apparatus, and apparatus fixed) ebrates

Standard of recognition (applicable date: November 15, 2001, from the date of medical treatment) for convergence alcoholic beverages (from the date of application)

Mebrates (Pedicle Fixization) and Cage (Equipment) using the post-deficial organization

Cype (Rgresory Fusion) of the recronrony crypty Cype (Rgresor) of the recrony crybrony crypty

without distinguishing the soft or soft system, it is recognized in the following cases:

1) Spodyloliss (vertebrate Bade) Grade II, III

2) In the case of Spondythic spoonylisisis Grade, both Isthmus (In the case of Spondythic spos defet

at the time of such occurrence;

3) Degegetable spondy losis (HIVD salt) and severe ndow in HIVD (HIV escape certificate)

ring is clearly verified by ray, and clinical symptoms caused by Forcminal Suros (vertec vertec chronum)

Recognition of only Level if accompanied by Narowing

4) Instrubil due to an operation, including Wides Facete omy (e.g., broad spine e.g., spine e.)

Where the nature of the security has been clearly established;

C. Part on the reduction of medical care benefit costs for △△△△

vertebrate marine is due to vertebrate, neute, or efficiencies, etc.; or

A disease that causes a variety of nephism, including a sporadic marism, due to a fladism;

F. If Gap evidence No. 6-1, Eul evidence No. 10, and No. 16 are gathered to the purport of the whole pleadings, △△△, respectively.

Between 4-5 and 2-3, vertebrate colonies at the time of the above procedure with respect to △△△△

In that respect, we did not observe the consensus in terms, and 3 - 4 in terms of the need for converging.

Recognizing the fact that only opinions have been observed (in this respect, the opinion on the vertebrate Madern Madern Madern

L among the statements in Gap evidence 6-1

2/3, 3/4 of the diagnostic parts are employed as they are for the diagnosis that external pressure is high on the front part of the light.

of △△△△△△, 2-3 of the △△△△△△, 3-4 of the verteline, and 5 of the verteline.

을 확인할 수 없는 점 , 한편 이른바 넛슨 현상은 단순 방사선 사진상 추간판의 위치에

in the form of a square line discovered, in which the nuclear in the side is in progress with the age increase;

Reduction of ingredients due to a change in the sloping, and reduction in the height of conical signboards in addition to the reduction of the protruding;

발생하여 추간판의 횡파열이 음영으로 나타나 보이는 현상인데 , 이러한 넛슨 현상의

임상적 의미가 아직까지 명백한 것은 아니므로 △△△의 제2 - 3요추간에 넛슨 소견이

It is impossible to readily conclude that there is any unstableness in the body of a woman on the basis of observation (hereinafter referred to as “marity”).

대 부속병원의 감정촉탁결과에 의하더라도 넛슨 소견이 있는 경우 불안정이 있는 경우

J.I.D. In all cases, if the time of stabilization may take place, the award to the Human Resources University of this Court.

According to the results of the fact-finding on the head of the Gyeyang Magsan Hospital, as well as other vertebrate diseases.

RS (Scolios Resarciety) studies on methods of determining the scope of ties in the exchange operation.

The conference official guidelines do not exist, and most of the spine ebrates or conical signboards removal methods do not exist.

vertebrate operations, which account for the State, shall be the body due to a wide range of organized dog or dye, etc. at the time of such operations.

It is accompanied by damage, and there may be a complication or ex post facto gift after the surgery, in particular:

Permanent obstacles, such as restrictions on spine exercise due to the unity of the same division, will remain, and on the expenses thereof

The economic burden is increasing (in reference, the number of spine surgery conducted in Korea is 2 △△△△△△).

22, 939 , 46, 301 , 64, 969 , approximately 283% for the year 202, and special cases;

In the case of the United States, the rate of increase in spine ebrate would be 75% compared to the rate of increase in 9 years in the 1980s.

In the case of Korea, 72% increase rate is shown during the period from 1999 to 2001.

As a result, the financial burden of national health insurance has increased rapidly, and therefore, the burden of national health insurance has increased rapidly.

In addition, taking into account all the circumstances shown in the instant case, such as the patient's age or the prevailing situation.

In the case of △△△△, there is no apparent opinion on the compromise of the inverte inverteline in the 2-3, 3-4.

c) even though the effect of such a compromise is not clear, it shall not be

The above hospital, which is a medical institution intentionally, is vertebrate livering with a device even between the above verteums.

It shall not be deemed to fall under any of the items of the above criteria for the examination of vertebrate drugs.

C. Therefore, this part of the Plaintiff’s assertion is without merit.

D. Part on the reduction of medical care benefit costs for △△ Group

If you gather the purport of the entire argument in each entry of the evidence 17-1 to 3 of this title, you can see that this title is a whole of the pleadings.

at the time of the above procedure 2-3 - 4 to the extent that the verte inverte inverte is observed, but the degree of such observation.

A. Since the fact that the symptoms appear only in the case of minor and patience may be recognized, the symptoms are given.

It is difficult to deem that a wide range of tension is a serious vertebrate freculs to the extent that it is inevitable.

In other words, the pressure pressure of the AlleyIs is one of the diseases that show good results by preserved methods.

(2) any competition accompanied by continuous pains or serious neurosis due to a progressive increase in the transformation;

the operation may only be a last means, but only by entry in Gap evidence 6-2 and 3

Even in the case of the above patient, e.g. e. e. e. vertebrate and less e.g. e. vertebrate according to the inspection opinion, 2, 3,

Duptures and 3-4 Puptures only observe the side cuptures, etc. of the latitude and longitude, and cuptures

It was confirmed that there was a strong pressure to the extent that it is necessary to conduct severe vertec vertecopher or surgery.

that there is insufficient evidence to acknowledge that there is no other evidence to acknowledge it (the reduction of an affiliated hospital)

Even according to the results of the due commission, it shall be evaluated as the vertebron febrates between the 3-4 verteums in the medical records

(1) Where the vertebrate vertecopic vertecopic vertecopic vertecopic vertecopic

(A) The problem of spine operation or the problem of the above patient, as seen above.

In full view of all the circumstances shown in the instant case, such as age and condition, the operation on △ Doz.

of the above criteria for assessment of vertebrate alcohol, which does not fall under any of the items, or which is the pressure of fladrity.

The Plaintiff’s assertion on this part can not be seen as a general treatment law on the alley.

No reason exists.

4. Conclusion

Thus, the plaintiff's claim of this case is dismissed as it is without merit, and the court of first instance shall do so.

Inasmuch as the conclusion is unfair with different conclusions, the defendant's appeal is accepted and the judgment of the first instance is revoked and the plaintiff

It is so decided as per Disposition by the assent of all participating Justices.

Judges Kim Jong-dae

Judges Lee Young-jin

Judges Kang Jong-chul

Relevant laws and regulations

The actual contents of the National Health Insurance Act (amended by Act No. 6951 of July 29, 2003)

Article 39 (Medical Care Benefits)

(1) The following medical care benefits shall be provided for the disease, injury, childbirth, etc. of policyholders and their dependents:

3. Treatment, operation and other treatment;

(2) The period of medical care benefits referred to in the provisions of paragraph (1) (hereinafter referred to as "medical care benefits") such as the method and scope and upper limit thereof.

Warrant officer shall be prescribed by Ordinance of the Ministry of Health and Welfare.

Article 43 (Claims for and Payment, etc. of Medical Care Benefit Costs)

(1) Medical care institutions may request the Corporation to pay medical care benefit costs. In this case, the examination referred to in paragraph (2) shall be made.

A claim shall be considered as a claim for medical care benefit costs against the Corporation.

(2) Any medical care institution that intends to claim medical care benefit costs referred to in paragraph (1) shall be subject to the case provided for in Article 55.

The Gangwon Insurance Review and Assessment Service shall request a review of medical care benefit costs, and the Health Review and Assessment Service shall receive a request for review

After examining the results, it shall be notified without delay to the Corporation and the medical care institution.

(5) In paying medical care benefit costs, the Corporation shall determine the provisions of Article 56 by the Health Insurance Review and Assessment Service under paragraph (2).

Where evaluating and notifying the Corporation the appropriateness of medical care benefits by determination, medical care benefit costs according to the results of such evaluation.

Additional or reduced amount shall be paid. In such cases, the criteria for the additional or reduced payment of medical care benefit costs based on the results of the evaluation;

women shall be prescribed by Ordinance of the Ministry of Health and Welfare.

1. As to the method and procedure of claiming, examining, paying, etc. medical care benefit costs under paragraphs (1) through (5) of this Article

Necessary matters shall be prescribed by Ordinance of the Ministry of Health and Welfare.

Article 56 (Operations, etc.)

(1) ① The Review and Assessment Service shall take charge of the following affairs:

1. Examination of medical care benefit costs;

2. Evaluation of the reasonableness of medical care benefits;

(2) Criteria, procedures, and methods for the evaluation of appropriateness of medical care benefits, etc. under paragraph (1) 2, 5, and 7.

Other necessary matters shall be determined by the Ordinance of the Ministry of Health and Welfare.

The actual contents of the National Health Insurance Act (amended by Ordinance of the Ministry of Health and Welfare No. 252 on June 30, 2003).

Article 13 (Examination and Payment of Medical Care Benefit Costs)

(1) When the Review and Assessment Service receives a request for review of medical care benefit costs, it shall Article 39 (2) and

The standards for medical care benefits under paragraph (3) and the details of medical care benefit costs under Article 42 of the Act;

In such cases, the president of the Review and Assessment Service shall review whether it is in conformity with the provisions of Article 12 or 83 of the Act.

If it is deemed necessary to verify whether the materials are true, the employees under his control shall be in charge of the matters in question.

such local business trip may be made to verify.

1 ② When conducting a review under paragraph (1), the Director of the Review Board shall request for review of medical care benefit costs.

Examination shall be conducted within 40 days from the date of receipt (15 days in the case of the electronic document exchange system under Article 14 (1)).

the Corporation and the relevant medical care institution, respectively, shall send a notice of the result of the review of the medical care benefit cost containing the content thereof;

The Corporation in receipt of the result of the examination of medical care benefit costs shall, without delay, receive the payment of medical care benefit costs.

Medical care benefit costs shall be paid to the relevant medical care institution by notification. In such cases, calculation of the period of review shall be made.

Special cases, such as where the director of the Review and Assessment Service requests the medical care institution which has requested for review of medical care benefits.

If there is any separate reason, the period required therefor shall be excluded.

(5) Forms of notice on the results of examination of medical care benefit costs and notice on the payment of medical care benefit costs, and examination and payment thereof.

Necessary matters shall be determined and publicly notified by the Minister of Health and Welfare.

Article 21 (Evaluation of Appropriateness of Medical Care Benefits and Allowances)

(1) Where the Review and Assessment Service evaluates the appropriateness of medical care benefits, etc. pursuant to Article 56 (2) of the Act.

In terms of medical and pharmaceutical aspects and cost-effective aspects, evaluation of whether the medical care benefit has been properly provided, and its balance;

shall disclose the results to the public.

(2) Evaluation under paragraph (1) shall be conducted by classifying by medical care institution, by specialized department or by injury and disease.

(3) Other detailed criteria, procedures, methods, etc. for evaluation of propriety shall be determined by the Minister of Health and Welfare.

of the corporation.

The actual tax rate shall be determined by the Regulations on the Standards for Medical Care Benefits for National Health Insurance (amended by the Ordinance of the Ministry of Health and Welfare No. 262 on November 10, 2003).

Of those)

Article 5 (Standards and Methods for Applying Medical Care Benefits)

(1) Medical care institutions shall provide medical care benefits for policyholders, etc. according to the criteria and methods for applying medical care benefits in attached Table 1.

section 23(3).

(2) Detailed matters concerning the standards and methods for applying medical care benefits under paragraph (1) shall be determined by the medical industry, the Corporation and the health insurance.

The Minister of Health and Welfare shall determine and announce after hearing the opinions.

[Attachment 1]

Standards and methods for applying medical care benefits (related to Article 5 (1))

1. General principles of medical care benefits;

A. Medical care benefits need to be provided in consideration of the insured’s age, gender, occupation, mental and physical condition, etc.

In case of recognition, an offense medically recognized for the promotion of patient's health based on accurate diagnosis;

shall be conducted in an optimal manner.

(c) medical care benefits shall be provided in an economically effective cost-effective manner;

2. Diagnosis, examination, treatment, operation and other treatment;

(a) Diagnosis and treatment, including various tests, shall be limited to cases where it is deemed necessary for medical treatment;

The purpose of the Gu shall not be the Gu.

(b) Hospitalization and treatment for the disease group determined and publicly announced by the Minister of Health and Welfare under subparagraph 2 of attached Table 2 of the Decree;

In the case of medical treatment such as examination, treatment, etc. which is medically appropriate for the period of hospitalization shall be entered concerned.

shall be provided including in the original treatment.

4. Provision of materials for medical treatment;

Materials for medical treatment shall be permitted, reported, or recognized pursuant to the Pharmaceutical Affairs Act or other relevant Acts and subordinate statutes (the efficacy, effect, and page of use)

(ii) to the extent of this Act appropriate for medical judgment depending on the symptoms of the patient.

The actual cost of medical care benefit costs shall be determined on the basis of criteria for review and payment of medical care benefit costs (Notice No. 2002 - 19 of the Ministry of Health and Welfare on March 23, 2002).

Article 4 (Examination of Medical Care Benefit Costs)

1. When the Review and Assessment Service receives a request for review of medical care benefit costs, it shall satisfy the following requirements:

shall examine whether or not. In such cases, the criteria for examination falling under subparagraph 4 shall be disclosed to the public.

1. Standards prescribed by the rules on the standards for medical care benefits under the provisions of Article 39 (2) and (3) of the Act;

2. Details of calculation of medical care benefit costs under Article 42 of the Act;

3. Guidelines for calculating medical care benefit costs determined by the Minister of Health and Welfare;

4. Other deliberations of the Medical Examination and Assessment Committee established by the president of the Review and Assessment Service under Article 59 of the Act.

Standards, etc. for examining medical care benefit costs determined through

(2) The Review and Assessment Service shall, in reviewing medical care benefit costs, have persons with medical expertise of the Medical Examination and Assessment Committee.

The examination shall be conducted in a fair and reasonable manner after receiving the text.