[1] Whether the Minister of Health and Welfare has broad discretion to change or adjust the relative value points of medical care benefits (affirmative with qualification)

[2] The meaning of “parties” to provide an opportunity to present their opinions in accordance with Article 22(3) of the former Administrative Procedures Act when an administrative agency imposes an obligation on a large number of unspecified persons or restricts their rights and interests, and whether a disposition that imposes an obligation on a large number of unspecified persons or restricts their rights and interests should be given an opportunity to present their opinions to the other party in accordance with the said provision

[1] In light of the legislative intent of the former National Health Insurance Act (wholly amended by Act No. 11141, Dec. 31, 201); Articles 4, 39, and 42 of the former Enforcement Decree of the National Health Insurance Act (amended by Presidential Decree No. 22190, Jun. 8, 2010); Articles 8, 12, 13, and 14 of the former Rules on the Standards for Medical Care Benefits in National Health Insurance (amended by Ordinance of the Ministry of Health and Welfare, Dec. 23, 2010); and the structure and contents of the provisions on medical care benefits, etc., the Minister of Health and Welfare may adjust the wide range of points of relative value of each medical care benefit regardless of the point of relative value of each medical care benefit between the National Health Insurance Corporation and its representative, insofar as the opinion of the interested parties on the medical care benefit cost does not seriously undermine the legislative intent of the aforementioned Act.

[2] Under Article 22(3) of the former Administrative Procedures Act (amended by Act No. 11109, Dec. 2, 2011; hereinafter the same), a “party”, which an administrative agency imposes an obligation on, or limits rights and interests, refers to a “party directly related to, the administrative agency’s disposition” (Article 2 subparag. 4 of the former Administrative Procedures Act). However, a disposition imposing an obligation on, or restricting rights and interests of, an unspecified number of persons by means of “public notice” cannot specify the other party who is given an opportunity to present his/her opinion, and thus, in such disposition, it does not mean that the other party should be given an opportunity to present his/her opinion pursuant to Article 22(3) of the former Administrative Procedures Act.

[1] Articles 4, 39 (see current Article 41), and 42 (see current Article 45) of the former National Health Insurance Act (wholly amended by Act No. 11141, Dec. 31, 201); Article 24 (see current Article 21) of the former Enforcement Decree of the National Health Insurance Act (Amended by Presidential Decree No. 22190, Jun. 8, 2010); Articles 8, 12, 13, and 14 of the former Rules on the Standards for Medical Care Benefits in National Health Insurance (Amended by Ordinance No. 30, Dec. 23, 2010); Article 22 (3) of the former Administrative Procedures Act (Amended by Act No. 1109, Dec. 2, 2011) / [2]

[1] Supreme Court Decision 2003Du11988 decided May 25, 2006 (Gong2006Ha, 1168)

Plaintiff 1 and three others (Law Firm Sejong, Attorneys Kim Sun-soo et al., Counsel for the plaintiff-appellant)

[Defendant-Appellant] Korea Medical Association (Law Firm Sejong, Attorneys Kim Sun-soo et al., Counsel for defendant-appellant)

The Minister of Health and Welfare (Law Firm Hun-Myeon, Attorneys Nam-Un et al., Counsel for the defendant-appellant)

Seoul High Court Decision 2011Nu14205 decided February 29, 2012

All appeals are dismissed. The costs of appeal are assessed against the Plaintiff’s Intervenor, and the remainder are assessed against the Plaintiffs.

The grounds of appeal are examined.

1. Regarding ground of appeal No. 1

A. Comprehensively taking account of Articles 4, 39, and 42 of the former National Health Insurance Act (wholly amended by Act No. 11141, Dec. 31, 2011); Article 24 of the former Enforcement Decree of the National Health Insurance Act (Amended by Presidential Decree No. 22190, Jun. 8, 2010); Articles 8, 12 through 14 of the former Regulations on the Standards for Medical Care Benefits in National Health Insurance (Amended by Ordinance of the Ministry of Health and Welfare No. 30, Dec. 23, 2010); ① Expenses for medical care benefits provided by a medical care institution shall be determined by the method determined by the contract between the chief director of the National Health Insurance Corporation and the person representing the medical industry; ② the period of contract shall be one year; ③ the point of relative value of medical care benefits shall be determined by taking into account the working hours, etc. required for the medical care benefits; and ④ the amount and risk of human resources among the organizations recommended by the National Health Insurance Policy Deliberative Committee; and the relative shall be defined as the relative.

As can be seen, contracts between the National Health Insurance Corporation and the representatives of medical and pharmaceutical circles regarding medical care benefit costs are limited to setting the "unit price for each medical care benefit" at the point of relative value of each medical care benefit. The point of relative value is limited to setting the "unit price for each medical care benefit," and there is no particular restriction on the revision. Meanwhile, as the factors to be considered in setting the point of relative value due to the development of medical science, changes in medical system, changes in relevant laws and regulations, etc., such as "the amount of duties, such as hours and effort required for medical care benefits, and the quantity of resources, such as human resources, facilities, and equipment, and the risk of medical care benefit, etc., are changed from time to time, it is necessary to adjust the corresponding point of relative value accordingly

In light of the structure, contents, etc. of the provision on medical care benefit costs, the Defendant may change or adjust the point of relative value of each medical care benefit regardless of the contract period regarding the “unit price” of the relative value of each medical care benefit between the National Health Insurance Corporation and the pharmaceutical’s representative, so long as the legislative intent of the above-related Acts and subordinate statutes is not significantly impaired, which is to determine medical care benefit costs corresponding to changes in the reality of medical care benefits by appropriately reflecting the opinions of interested parties on the medical care benefit costs. Therefore, the Defendant ought to have a broad discretion in relation thereto (see Supreme Court Decisions 2003Du11988, May 25, 2006; 2012Du19472, Jul. 10, 2014, etc.).

B. According to the reasoning of the judgment below, after the introduction of the first comprehensive water system with respect to seven disease groups, including the 2002 modified body surgery, the Defendant determined that there is a need to adjust the number of diseases by reflecting the changes in the form of medical treatment, such as the reduction of the number of hospitalization days, and the fluctuation in the prices of medicine and materials for medical treatment due to the development of medical technology, etc. In light of the above, around June 2008, the Defendant requested research on how the comprehensive water system has been developed through the Health Insurance Review and Assessment Service. The above two industry-academic cooperation foundations provided research services on the development of the system to medical institutions after collecting and analyzing the data through surveys, statistics surveys, etc., and based on the results, submitted a final report stating the "Research on the Development of the System of Mag Disease (DG)," and according to the report, the Defendant should be able to identify the average number of days of hospitalization in the modified body operation, the degree of relative value points of the previous 20% of the disease’s treatment surgery and the previous 20% of health insurance premium.

In light of the aforementioned legal principles, the Defendant’s determination and notification of the relative value points of the disease group related to the modified surgery is in accordance with the former National Health Insurance Act and subordinate statutes, and the content thereof cannot be deemed as a deviation from and abuse of discretion when it severely damages the purport of relevant statutes, such as Article 42(1) of the former National Health Insurance Act.

C. Therefore, the court below was just in holding that the notice of this case was lawful, and there was no error in the misapprehension of the legal principles as to the defendant's authority to make the notice of the adjustment of the relative value point point point point, or in failing to exhaust all necessary deliberations in relation thereto.

2. Regarding ground of appeal No. 2

A. Under Article 22(3) of the former Administrative Procedures Act (amended by Act No. 11109, Dec. 2, 2011; hereinafter the same), “party”, which an administrative agency imposes an obligation on and imposes an opportunity to present opinions when restricting rights and interests, refers to a “party directly related to the administrative agency’s disposition” (Article 2 subparag. 4 of the former Administrative Procedures Act). However, a disposition imposing an obligation on a large number of unspecified persons by means of “public notice” or restricting rights and interests, cannot specify the other party who is given an opportunity to present his/her opinions, and thus, in such disposition, it does not mean that the other party should be given an opportunity to present his/her opinions pursuant to Article 22(3) of the former Administrative Procedures Act.

B. Based on its reasoning, the lower court determined that the Defendant’s disposition to reduce the relative value points of the disease group related to a modified body surgery to about 10 to 25% by the instant notice cannot be deemed unlawful on the ground that the Defendant did not provide the other party with an opportunity to present his/her opinion in accordance with Article 22(3) of the former Administrative Procedures Act, on the ground that the disposition based on the instant notice was not against the individual awareness and doctor who established and operated the medical institution operating the modified body, but against the whole of unspecified doctors.

C. Such determination by the lower court is justifiable in light of the legal doctrine as seen earlier, and it did not err by misapprehending the legal doctrine regarding the scope of disposition to be given an opportunity to present opinions pursuant to Article 22(3) of the former Administrative Procedures Act.

3. Conclusion

Therefore, all appeals are dismissed, and the costs of appeal are assessed against the losing party. It is so decided as per Disposition by the assent of all participating Justices on the bench.

Justices Kim Chang-suk (Presiding Justice)