[1] Whether fraud is established in a case where a medical institution received medical expenses by claiming an insurance company to pay excessive medical fees (affirmative)

[2] The case holding that in a case where a medical institution was expected to reduce medical fees in advance and the insurer was paid medical fees which were not actually incurred by an insurance company after falsely claiming medical fees, the intention of defraudation and intent of unlawful acquisition of the portion of the claim for false and exaggerated fees is recognized

[1] Article 347 (1) of the Criminal Code / [2] Article 347 (1) of the Criminal Code

[1] Supreme Court Decision 2005Do1876 Decided September 28, 2005

Defendant

Defendant

Cheongju District Court Decision 2005No1188 Decided August 16, 2006

The appeal is dismissed.

The grounds of appeal are examined.

The medical fee covered by automobile insurance is determined and paid in accordance with the procedure prescribed by the relevant Acts and subordinate statutes. An insurance company is not allowed to arbitrarily claim or reduce the amount of medical fee, and an insurance company can file a petition for review with the Medical Fee Dispute Resolution Council for the unfair reduction measures of the insurance company. Nevertheless, in a case where the insurance company anticipated the reduction of the medical fee claimed by the medical institution in advance and claimed the medical fee in a false manner, it shall be deemed that there was an intention to obtain fraud and illegal acquisition of the portion of the medical fee claimed falsely (see Supreme Court Decision 2005Do1876, Sept. 28, 2005). Moreover, since it is recognized that the medical fee claimed by the medical institution has been established as a practice or implied intent to reduce the amount by 10-15%, it cannot be said that there is no possibility of expectation or illegality of the lawful act of using the medical fee claimed by the medical institution, and it cannot be said that there is no damage to the insurance company merely because the amount actually received through a false or excessive claim is not a large amount.

In light of the above legal principles and records, it is justified that the court below found the defendant guilty of each criminal fact in the judgment on the ground that the defendant filed a claim for medical expenses not actually incurred by the defendant and received them from the insurance company, and there is no violation of the rules of evidence or misapprehension of legal principles as alleged in the grounds of appeal.

Therefore, the appeal is dismissed. It is so decided as per Disposition by the assent of all participating Justices on the bench.

Justices Park Si-hwan (Presiding Justice)