[1] Whether cancellation of designation of a medical institution in charge of additional medical care under the Industrial Accident Compensation Insurance Act constitutes an administrative disposition (affirmative)

[2] The case holding that the revocation of the designation of a medical institution in charge of additional medical care under Article 6 (1) 3 of the Industrial Accident Compensation Insurance Management Regulations was unlawful on the ground that each claim for unjust payment of medical expenses is substantially less than one million won per time

[1] The cancellation of the designation of a medical institution in charge of additional medical care for a medical institution violating the laws and regulations of the Korea Workers' Compensation and Welfare Service is one of the administrative actions that the Korea Workers' Compensation and Welfare Service designates a medical institution in charge of medical care in accordance with Article 40(1) of the Industrial Accident Compensation Insurance Act, Article 28(2) of the Enforcement Decree of the same Act, and Article 6(1)3 of the Regulations on the Management of Industrial Accident Compensation Insurance Management in order to efficiently handle the industrial accident compensation insurance business, and is limited to an industrial accident patient, even though the designation is revoked and the re-designation is prohibited for a certain period, the medical institution designated as a medical institution in charge of medical care will cause enormous decrease in income by preventing industrial accident patients from treating and treating them, and thus, the cancellation of the designation of a medical institution in charge of medical care is a sanction that directly affects the rights and duties of the person who established the medical institution, and thus constitutes an administrative disposition subject to appeal litigation.

[2] The case holding that the revocation of the designation of a medical institution in charge of additional medical care under Article 6 (1) 3 of the Industrial Accident Compensation Insurance Management Regulations is unlawful on the ground that the amount of the fraudulent claim for each medical expenses substantially falls short of one million won per time

[1] Article 40 of the Industrial Accident Compensation Insurance Act, Article 28 of the Enforcement Decree of the Industrial Accident Compensation Insurance Act, Article 17 of the Enforcement Rule of the Industrial Accident Compensation Insurance Act, Article 6(1)3 of the Industrial Accident Compensation Insurance Act, Article 2 of the Administrative Litigation Act / [2] Article 40 of the Industrial Accident Compensation Insurance Act, Article 28 of the Enforcement Decree of the Industrial Accident Compensation Insurance Act, Article 17 of the Enforcement Rule of the Industrial Accident Compensation Insurance Act, Article 6(1)3 of the Industrial Accident Compensation Insurance

Choi Jin (Law Firm, Kim & Lee, Attorneys Yellow-man et al., Counsel for the plaintiff-appellant)

Korea Workers' Compensation and Welfare Corporation (Law Firm Han, Attorney Hwang Tae-sung, Counsel for defendant-appellant)

May 19, 1999

1. On October 22, 1998, the order defendant revoked the cancellation of the designation of medical institution in charge of additional medical care for the plaintiff on October 22, 1998.

2. The costs of lawsuit shall be borne by the defendant.

The same shall apply to the order.

1. Details of the disposition;

The following facts are acknowledged in light of each of the statements of Gap 1, 9, 10, 12-1 through 6, 2, 13, 7-1, 2, 4-1 through 22, 11 through 16, 1-1, 2, 2-2, 2-3, and 3-1, 1-1, 1-2, 2-2, 2-3, 3 of the testimony of Kim Jong-hee, and the whole purport of the pleadings:

A. The plaintiff obtained a doctor's license on May 1, 1975 and recognized the qualification of a medical specialist on March 25, 1980, and since around 1983 when the plaintiff served as a medical specialist, from the Korea Coal Corporation's staff members affiliated with the Korea Coal Corporation, the plaintiff provided medical services to the mine workers belonging to the above Corporation and their families. On February 3, 1995, the plaintiff established "the Korea Coal Corporation" as a general source. On September 22, 1995, the plaintiff applied for the designation of a medical institution in charge of industrial accident compensation insurance to the defendant on the 29th of the same month (hereinafter referred to as the "Act") pursuant to Article 40 (1) of the Industrial Accident Compensation Insurance Act and Article 28 (1) of the Enforcement Decree of the same Act (hereinafter referred to as the "Enforcement Decree"), 30% of the number of patients suffering from industrial accident and 50% of the total number of patients suffering from industrial accident, and 30% of the number of patients suffering from industrial accident.

B. However, on August 2, 1998, the Plaintiff reported the accusation program, “KBS S S S S S S S S S S S S S S S S S SP,” that “the Plaintiff received excessive medical expenses by unlawful means, such as manipulating the grade or treatment period of industrial accident patients by mutual ties between the patients and doctors at a medical institution in charge of receiving additional medical care in the mine area, such as Taekba, Don, etc., and some employees of the Defendant Corporation.” As such, the Plaintiff was subject to a special audit on whether there was excessive and unfair medical expenses from the office of the main auditor of Defendant Corporation, along with the Korea Medical Service Chairperson, who is another medical institution in charge of medical care in the Do area indicated in the foregoing report from the 22th to the 29th day

C. On August 28, 1998, the Special Audit Team of Defendant Corporation visited the above Do mining center to examine 16 patients who were hospitalized in the course of 28 out of the total number of industrial accident patients. After having asked the patients about whether they received physical treatment, how they received treatment or not, and whether they received it in son’s machine, etc., they did not properly respond to the specific contents of the Campaign Act which was performed even after being treated with the Act, so the patients who lack of accurate understanding of the said Act did not properly respond to the specific contents of the Campaign Act. The report that the Plaintiff filed a claim for medical expenses for physical treatment of patients without implementing the Act at all, and the result of the interview that the Plaintiff requested the Plaintiff to prepare and affix a confirmation document that the Plaintiff did not implement the Campaign Act for the above patients through 2-year meeting, which is the head of the above member’s office, for up to 9 years (the Plaintiff did not request the auditor to complete the above 9-year interview with his opinion that he did not meet the above 9-year audit and inspection procedure.

D. The Defendant: (a) If the medical institution in charge of the medical care seeks to claim medical expenses for physical care, it must be the case where the medical institution actually provides treatment for physical care; (b) even if the physical care was provided for more than twice a day, it can claim only once a day; (c) however, during the period from March 30, 1998 to June 30 of the same year, the Plaintiff did not provide treatment for the patients at all, and filed a claim for one-time or twice medical treatment for the Defendant one-day medical expenses; and (d) as stated in the table Nos. 6 to 8 of the Claim No. 1998, the Defendant received KRW 3,283,210 (including additional charges); and (d) the Plaintiff’s claim for the cancellation of the designation of the medical institution by applying the aforementioned provision No. 15-day Medical Care Act from January 1 to 31, 1997; and (e) the Plaintiff’s claim for removal of the designation of the medical institution as the one-day Medical Care Act.

E. The Medical Care Act is a physical treatment method for the purpose of treating the patient’s body by means of detailed exercise or exercise using various devices, recovery of physical functions, disorder in skills of surrounding land and pipes, and breath and breath, etc. In addition to the method of directly performing the patient’s body, it may be possible for physical treatment at the same time for several patients at the same time. However, according to Article 40(4) of the Act and Article 17(1) of the Enforcement Rule of the Act, the Minister of Health and Welfare’s announcement that provides the basis for medical care benefits pursuant to Article 40(4) of the Act and Article 17(1) of the Enforcement Rule of the Act, which provides for the calculation of medical care benefits for 6 months at least twice a day, 60-day medical treatment expenses for the six-month period, 70-day medical treatment expenses for the patient who provided the Sports Act at least twice per six months, and 9-day medical treatment expenses for the Defendant’s 20-day medical treatment expenses for the six-month period.

2. Determination on this safety defense

A. With respect to the lawsuit in this case seeking the cancellation of the above designation, the defendant is an administrative disposition subject to the administrative litigation, which is a law enforcement on the specific facts conducted by an administrative agency as the public authority, and refers to the act of directly related to the rights and obligations of the people. The act of designating a medical institution in charge of medical care is based on the premise that the medical institution and the founder of the medical institution enter into a contract in charge of medical care with the founder of the medical institution to take charge of medical care benefits as prescribed by the law, the medical institution concerned acquires the right to claim reimbursement of medical care expenses to the defendant, while the contract in charge of medical care, which is a substantive premise of such designation, loses the right to claim medical care expenses to the patient in question within the limit. The contract in charge of medical care, which is a substantive premise of such designation, is a private contract established with the consent of the defendant such as the application for designation of the medical institution and the designation decision of the medical institution. The Industrial Accident Compensation Insurance Act does not have any explicit basis for the designation and cancellation of the contract in this case.

B. Therefore, in order to efficiently deal with industrial accident compensation insurance business, the defendant designated a medical institution in charge of medical care in accordance with Article 40(1) of the Act, Article 28(2) of the Enforcement Decree of the Act, and the above treatment regulations, and cancelled the designation of a medical institution in charge of medical care to a medical institution in charge of violation of Acts and subordinate statutes as one of the administrative actions conducted in a superior position supervising him/her and supervising him/her, and even though the subject of medical care is limited to an industrial accident patient, a medical institution designated as a medical institution in charge of medical care shall be cancelled, and if re-designation is prohibited for a certain period, it will cause enormous decrease in revenues and great trouble in its operation by preventing him/her from treating and treating the industrial accident patient. Thus, the cancellation of the designation of a medical institution in charge of medical care shall be a disciplinary measure that directly gives considerable disadvantage to the founder of the medical institution concerned, which directly affects his/her rights and duties, and thus, the defendant's defense of safety cannot be accepted.

3. Whether the disposition is lawful;

However, Article 6 (1) 3 of the above Treatment Regulation, which is the basis for the disposition of this case, provides that the head of a branch office shall cancel the designation of a medical institution in charge of the medical treatment, where the medical institution does not actually provide medical treatment or where the medical institution claims medical expenses different from the medical record, water treatment expenses and outpatient treatment expenses claimed without possessing water treatment equipment or equipment, and false means such as request for food care for patients staying outside the country, but this provision does not apply where the amount of fraudulent claim is less than one million won. Thus, the plaintiff prepared a written confirmation that the plaintiff claimed medical expenses for patients suffering from medical treatment without providing medical treatment at all. Since the plaintiff claimed medical expenses more than one day by claiming medical expenses, the plaintiff's excessive payment of medical expenses from the defendant exceeds one million won by claiming medical expenses more than one hundred thousand won per day, the plaintiff's allegation that the amount of fraudulent claim for medical expenses did not reach one million won per time, and the plaintiff's claim for medical expenses cannot be denied under the premise that the amount of the above medical institution's claim for treatment is no more than one million won per day.

4. Conclusion

Thus, since the disposition of this case was conducted without any ground for disposition and is illegal, the plaintiff's claim of this case seeking its revocation is reasonable and it is so decided as per Disposition.

Judges Kim Jong-il (Presiding Judge)