[1] Standard for determining whether the provision of medical care benefits and the receipt of medical care benefits in violation of other individual administrative laws constitute “the payment of insurance benefits costs by continuous or other unlawful means” as the subject of unjust enrichment collection under Article 57(1) of the former National Health Insurance Act

[2] Where a medical care institution provides patient meals to the insured or their dependents without reporting the installation of meal service facilities by meeting the requirements for human resources and facilities under the Food Sanitation Act, whether the act of the medical care institution receiving food-related medical care benefit costs constitutes “the act of receiving medical care benefit costs by continuous or other unfair means” under Article 57(1) of the former National Health Insurance Act (negative)

[1] The former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter “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, medical treatment, rehabilitation, childbirth, death, and improvement of health of diseases and injuries. Accordingly, whether the provision of medical care benefits and the receipt of medical care benefits in violation of other individual administrative laws constitutes “the cost of insurance benefits by fraud or other improper means” as provided for the collection of unjust enrichment under Article 57(1) of the National Health Insurance Act should be determined by taking into account the legislative purpose and purpose of each individual administrative law different from the National Health Insurance Act and the difference in the subject of regulation under the National Health Insurance Act, and the need and degree of the collection of unjust enrichment under the National Health Insurance Act, other than sanctions under other individual administrative laws.

[2] The purport of the Medical Care Benefit Rules, etc. on the Medical Care Benefit Standards for National Health Insurance provides patient meals at a medical care institution that meets the standards for human resources and facilities under the Food Sanitation Act, is to allow a medical care institution to provide sanitary meals suitable for the treatment of patients, or not to fulfill the reporting on the establishment and operation of meal service facilities. In addition, it is difficult for a medical care institution to recognize the need for public interest to the extent of unjust enrichment collection under the National Health Insurance Act, in addition to imposing a fine for negligence under the Food Sanitation Act, where it violates its obligation to report in advance in the establishment and operation of meal service facilities, in addition to imposing a fine for negligence under the Food Sanitation Act.

Therefore, if a medical care institution provides the health insurance policyholders or their dependents with patient meals by meeting the requirements for human resources and facilities under the Food Sanitation Act, even if it provides meals without reporting the establishment of meal service facilities, it cannot be deemed that the medical care institution’s receipt of the cost of health care benefit related to food constitutes “the act of receiving the cost of health care benefit by continuous or other improper means.”

[1] Article 57 (1) of the former National Health Insurance Act (Amended by Act No. 13985, Feb. 3, 2016) / [2] Articles 41 (2) (see current Article 41 (3) and 57 (1) of the former National Health Insurance Act (Amended by Act No. 13985, Feb. 3, 2016); Article 5 (1) [Attachment Table 1] subparagraph 6 (c) of the Regulations on the Standards for Medical Care Benefits in National Health Insurance; Article 1, 2 subparagraph 12 (c) of the former Food Sanitation Act (Amended by Act No. 11690, Mar. 23, 2013); Articles 71, 72, 74, 88 (1), (2), (3), and 101 (2) and 101 subparagraph 1 of the former Food Health Insurance Act (Amended by Act No. 11690, Mar. 23, 2013)

[1] Supreme Court Decision 2015Du36485 Decided May 30, 2019 (Gong2019Ha, 1310)

Plaintiff

National Health Insurance Corporation (Attorney Kim Han-soo, Counsel for defendant-appellant)

Seoul High Court Decision 2017Nu41438 decided August 16, 2017

The judgment below is reversed and the case is remanded to Seoul High Court.

The grounds of appeal are examined.

1. As to the assertion that there is no ground for disposition of unjust enrichment collection

(1) The former National Health Insurance Act (amended by Act No. 13985, Feb. 3, 2016; hereinafter “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, medical treatment, and rehabilitation of diseases and injuries, for childbirth and death, and for the improvement of health (hereinafter “National Health Insurance Act”), and is different from the legislative purpose and subject of regulation (see Supreme Court Decision 2015Du36485, May 30, 2019). Therefore, whether the provision of health care benefits and the receipt of health care benefits in violation of other individual administrative laws constitutes “the payment of the cost of health care benefits by fraud or other improper means” under Article 57(1) of the National Health Insurance Act ought to be determined in consideration of the legislative purpose and subject matter of regulation different from the National Health Insurance Act and the need to take into account the difference between the legislative purpose and subject matter of regulation under the National Health Insurance Act and other individual administrative laws.

(2) Article 41(2) of the National Health Insurance Act provides that the method, procedure, scope, upper limit, etc. of health care benefit shall be prescribed by Ordinance of the Ministry of Health and Welfare. Article 5(1) of the Regulations on the Standards for Health Insurance Benefits under National Health Insurance provides that a health care institution shall provide health care benefit to the insured, etc. according to the criteria and method for the application of health care benefit under attached Table 1, and the above Rule [Attachment 1] subparagraph 6(c) of the attached Table 1 provides that meals to inpatients shall be provided in a sanitary manner at the level appropriate for the treatment of patients according to the standards

Meanwhile, the purpose of the former Food Sanitation Act (amended by Act No. 11690, Mar. 23, 2013) is to contribute to the improvement of national health by preventing sanitary danger and harm caused by food, promoting the qualitative improvement of food nutrition, and providing accurate information on food (Article 1). The term “facilities providing meals” refers to hospitals, etc. that continuously provide food to many and specified persons without seeking profit-making purposes (Article 2 subparag. 12(c)), and a person who intends to establish and operate facilities providing meals shall report to the Governor of a Special Self-Governing Province, the head of a Si/Gun/Gu, as prescribed by Ordinance of the Ministry of Health and Welfare (Article 88(1)); and a person who establishes and operates facilities providing meals shall comply with matters necessary to manage meal services, such as the maintenance and management of facilities providing meals (Article 88(2)). Article 88(1)1 of the same Act provides for an administrative fine not exceeding five million won, and a person who fails to comply with an order to install and operate facilities under Article 88(2).10(3).

(3) Comprehensively taking account of the aforementioned legal principles and the content of the relevant statutes, the purport of the provision that medical care benefit costs should be paid in a case where the National Health Insurance Rules, etc. provide patient meals at a medical care institution meeting the standards for human resources and facilities under the Food Sanitation Act is to enable a medical care institution to provide sanitary meals suitable for patient treatment, and cannot be deemed to have fulfilled the reporting on the establishment and operation of meal service facilities. Furthermore, it is difficult to recognize the necessity of public interest to the extent that it should be deemed to be subject to unjust enrichment collection under the National Health Insurance Act, in addition to imposing sanctions on a medical care institution that violates its obligation to report in advance under the Food Sanitation Act while establishing and operating meal service facilities.

Therefore, if a medical care institution provides the health insurance policyholders or their dependents with patient meals by meeting the requirements for human resources and facilities under the Food Sanitation Act, even if it provides meals without reporting the establishment of meal service facilities, it cannot be deemed that the medical care institution’s receipt of the cost of health care benefit related to food constitutes “the act of receiving the cost of health care benefit by fraud or other improper means.”

(4) Nevertheless, the lower court recognized that the Plaintiff received medical care benefit costs for meals provided prior to a report on the establishment of meal service facilities, and determined that the Plaintiff’s claim for the said medical care benefit costs constituted “a case where the Plaintiff received the insurance benefit costs by fraud or other improper means” as the subject of unjust enrichment collection under Article 57(1) of the National Health Insurance Act. In so determining, the lower court erred by misapprehending the legal doctrine on the criteria for medical care benefits and the subject of unjust enrichment collection under

2. Conclusion

Therefore, without further proceeding to decide on the remaining grounds of appeal, the judgment of the court below is reversed, and the case is remanded to the court below for a new trial and determination. It is so decided as per Disposition by the assent of all participating Justices

Justices Min You-sook (Presiding Justice)