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

National Health Insurance Corporation

March 25, 2020

Seoul Administrative Court Decision 2018Guhap64566 decided August 22, 2019

1. The plaintiff's appeal is dismissed.

2. The costs of appeal shall be borne by the Plaintiff.

The judgment of the first instance is revoked. The Defendant’s disposition to recover medical care benefit costs of KRW 996,616,970 against the Plaintiff on February 12, 2018 shall be revoked.

1. Quotation of the first instance judgment

The reasoning of this Court’s reasoning is as follows, and the reasoning of the judgment of the court of first instance is the same as that of the judgment of the court of first instance. Thus, this Court’s reasoning is cited in accordance with Article 8(2) of the Administrative Litigation Act and the text of Article 420 of the Civil Procedure Act.

2. Parts to be removed or added;

In the 11th sentence of the 7th sentence of the first instance judgment, the "Detailed Rules on the Standards and Methods for Applying Medical Care Benefits" shall be construed as "the "List of Benefit and Benefit Points Points of Health Insurance Act", and "The Points of relative Points of Benefit and Benefit Table of Health Insurance Act" in the 13th through 14th sentence shall be construed as "the Standards and Methods for Applying Medical Care Benefits", respectively.

○ The following is added to the 16th 16th 16th 16th 16th 16th 202.

In the case of Nonparty 1, the plaintiff asserts that he provided medical treatment at the hospitalization room of the ○○○○○○○○○○○○○ upon the request of Nonparty 2, the guardian, but even according to the plaintiff's argument, Nonparty 2, the nurse of the ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○’

○ In the first instance court’s 10th 15th 16th 15th 16th 10 to 16th 16th 201, the case of “case of receiving insurance benefits costs by deceit or other unjust means as “case of receiving insurance benefits by means of” under Article 57(1) of the National Health Insurance Act or by other unjust methods.

3. Additional determination

A. The plaintiff's assertion

1) The language and text of the instant disposition alone is in violation of Article 33(1) of the Medical Service Act, or it is unlawful because it is not clear whether the documents confirming the reason for the disposition was against Article 33(1) of the Medical Service Act, or whether the documents confirming the reason for the disposition were not submitted to the Health Insurance Review and Assessment Service, which were submitted to the Health Insurance Review and Assessment Service for the joint use of the facilities, human resources, and equipment of other health care institutions (hereinafter “the details

2) In order to collect unjust enrichment based on Article 57(1) of the National Health Insurance Act, there is a need for public interest to impose sanctions on the subject of unjust enrichment collection under the National Health Insurance Act. Even if the Plaintiff violated the details of the instant case, it cannot be deemed that there is a need for public interest to recover the medical care benefit cost. Even if the Plaintiff violated Articles 33(1) and 39(1) of the Medical Service Act, it cannot be deemed that there is a need for public interest to impose sanctions on the subject of unjust enrichment collection under the National Health Insurance Act, in addition to individual administrative disposition under the Medical Service Act. Thus, the instant disposition

B. Determination

1) Determination as to the assertion that the grounds for disposition are unclear

A) Article 23(1) of the Administrative Procedures Act provides that, when an administrative agency takes a disposition, the administrative agency shall present the grounds and reasons therefor to the parties. This purport is to exclude the arbitrary decision of the administrative agency and to enable the parties to properly cope with the administrative remedy procedure. Therefore, in full view of the contents stated in the written disposition, related statutes, and the overall process, etc. up to the relevant disposition, where it is sufficiently known whether the disposition was taken by the parties for any reason, and where it is deemed that there was no particular hindrance to the party’s objection to taking the disposition into the administrative remedy procedure, the disposition cannot be deemed unlawful due to such failure, even if the grounds and reasons for the disposition are not specified in the written disposition (see Supreme Court Decision 2011Du18571, Nov. 14, 2013).

B) Further to the facts acknowledged in the first instance trial and the overall purport of the arguments and evidence as seen earlier, the following circumstances are revealed in the instant disposition: ① (i) the Defendant revealed in the instant disposition that “the instant member’s medical care benefit is recovered pursuant to Article 57 (Collection of Unjust Enrichment) of the National Health Insurance Act since the violation of the standards for calculating physical treatment and the unfair claim for medical care benefit was confirmed after being hospitalized outside of the opening institution; and (ii) indicated in Articles 33(1) and 33(5) of the Medical Service Act; (iii) the Defendant, in the on-site investigation, examined the part of the instant disposition on which the Plaintiff was hospitalized at the ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ hospital’s hospital.

2) Determination as to the assertion that there is no need for public interest to make a proposal from the perspective of unjust enrichment collection

A) The National Health Insurance Act was enacted for the purpose of contributing to the improvement of national health and the promotion 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 health (see Supreme Court Decision 2015Du36485, May 30, 2019). 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 “the cost of insurance benefits by fraud or other improper means” under Article 57(1) of the National Health Insurance Act should be determined in consideration of the legislative purpose and purpose of the provision of insurance benefits under the National Health Insurance Act and the degree of necessity for collecting unjust enrichment under the National Health Insurance Act, other than sanctions under other individual administrative laws (see Supreme Court Decision 2015Du36485, Nov. 28, 2019; Supreme Court Decision 201Du5794, Apr. 29, 2017).

B) Comprehensively taking account of the circumstances acknowledged by the first instance court and the overall purport of the evidence and arguments as seen earlier, it is reasonable to deem that the Plaintiff received the insurance benefit cost by “a continuous and other unfair means” as prescribed by Article 57(1) of the National Health Insurance Act. Therefore, the Plaintiff’s above assertion is without merit.

① Article 33(1) of the Medical Service Act provides that no medical person may engage in the business of medical treatment without establishing a medical institution, and, in principle, allow the relevant medical institution to provide medical services only within the relevant medical institution, and criminal punishment is imposed against those who violate Article 90 of the same Act. The foregoing provision aims to prevent any deterioration in the quality of medical treatment and any infringement of the patient’s right to receive appropriate medical treatment from the outside of the medical institution established by the person himself/herself, thereby impairing the medical order and causing serious risks to public health and sanitation, thereby allowing the national health insurance holders, etc. to receive optimal medical treatment.

② Article 41(3) of the National Health Insurance Act provides that the criteria for 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 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 policyholders, etc. according to the criteria and methods for the application of health care benefit under attached Table 1. [Attachment Table 1] 1. E. (e) provides that the general principle of health care benefit for policyholders, etc. may be jointly utilized for high-quality facilities, human resources, and equipment possessed by other health care institutions as determined and publicly notified by the Minister of Health and Welfare. Accordingly, the joint utilization of facilities, etc. of other health care institutions is permissible when it is necessary to provide optimal health care benefit to subscribers,

③ Under the delegation by the National Health Insurance Act, the detailed provisions on the standards and methods for the application of medical care benefits under the National Health Insurance Act provides that medical care institutions that intend to jointly use the facilities, human resources, equipment, etc. of medical care institutions shall jointly use documents confirming that they are joint-use institutions after submitting them to the Health Insurance Review and Assessment Service. The Health Insurance Activity’s Schedule and the relative point of relative values of benefits provide that medical care benefits shall be included in cases where a full-time physical care institution provides physical care to the insured, etc.

④ Article 33(1) of the Medical Service Act and the National Health Insurance Act and the National Health Insurance Act provide citizens with appropriate medical care benefits for the prevention, diagnosis, and rehabilitation of diseases and injury, as well as for childbirth, death, and improvement of health. However, it is reasonable to deem that there is a need to collect unjust enrichment from the National Health Insurance Act, in addition to sanctions under the Medical Service Act, by providing medical care benefits in violation of Article 33(1) of the Medical Service Act and the National Health Insurance Act and the National Health Insurance Act and subordinate statutes, and by providing them with appropriate medical care benefits. The Plaintiff provided medical care benefits in violation of the criteria for medical care benefits under the National Health Insurance Act and the National Health Insurance Act and subordinate statutes, thereby impairing the legislative intent of each of the above Acts and subordinate statutes, such as improving national health and promoting social security. In addition to sanctions under the Medical Service Act, there is need to collect unjust enrichment from the National Health Insurance Act.

4. Conclusion

Thus, the plaintiff's claim shall be dismissed as it is without merit. Since the judgment of the court of first instance is just in conclusion, the plaintiff's appeal is dismissed as it is without merit.

Judge Lee Chang-type (Presiding Judge)