Cases
2011du5490 Revocation of revocation of disposition to examine the settlement of medical care benefit costs
Plaintiff, Appellee
Medical Corporations, ○ Foundation
Daejeon MN
Representative Director
Attorney omitted
Defendant, Appellant
Health Review Service
Representation of Representative Director
Attorney omitted
Judgment of the lower court
Seoul High Court Decision 2010Du14659 Decided February 1, 2011
Imposition of Judgment
July 14, 2011
Text
The judgment below is reversed, and the case is remanded to Seoul High Court.
Reasons
The grounds of appeal are examined.
According to the reasoning of the judgment of the court below, upon citing the reasoning of the judgment of the court of first instance, the court below acknowledged the following facts: (a) the Plaintiff operating AAA Special Hospital, an institution providing medical care, reported to the Defendant on the current status of the operation of beds and the number of nursing workforce to calculate the differential hospital admission fee system (Article 2007 - 139, hereinafter referred to as “the detailed notification of this case”); (b) the Defendant decided on the assessment of medical care costs by adjusting the level of the Plaintiff’s nursing workforce as class 3 according to the above report, but decided on the assessment of medical care costs according to the level of the level of securing the Plaintiff’s nursing workforce as class 6; and (c) decided on the determination of the settlement of accounts of this case that reduces medical care costs based on the results of the on-site investigation; (d) the head of the nursing department, the head of the nursing department, who reported the Plaintiff as nursing workforce, together with nursing supervision services, as well as nursing care supervision services; and (e) determined that this country was unlawful since it deviates or abused its discretionary relationship.
However, such determination by the court below is difficult to accept for the following reasons.
Even if a certain administrative act is a binding act or a discretionary act, whether it is a binding act or a discretionary act can not be uniformly defined, and whether it is a discretionary act or a discretionary act should be determined individually in accordance with the form of the provision or the language and text on the basis of the pertinent disposition (see Supreme Court Decision 97Nu15418, Dec. 26, 1997, etc.).
Article 7(2) of the Medical Care Assistance Act (amended by Act No. 9932, Jan. 18, 2010) provides for the methods, procedures, scope, and upper limits of medical benefits, and the standards for medical fees and the methods of calculating such standards. According to Articles 6 and 8 of the Enforcement Rule of the Medical Care Assistance Act, and Articles 5(2) and 1 and 8(2) of the Regulations on the Standards for Medical Care Benefits, detailed matters concerning the standards for and methods of medical benefits are to be prescribed by the Minister of Health and Welfare. Accordingly, the instant detailed matters prescribed in the form publicly notified by the Minister of Health and Welfare refer to a nurse in exclusive charge of nursing services in a convalescent hospital according to the level of nursing workforce, and a nurse who assists in nursing services in a convalescent hospital. According to the list of health insurance benefit, non-rating benefit, and the average level of nursing personnel at least 1% among those of the average level of nursing personnel at issue, the aforementioned average level of nursing personnel at least 9% can be determined.
However, even based on the facts acknowledged by the court below, insofar as the head of the Plaintiff hospital's nursing division concurrently provides nursing supervision services in addition to the nursing services for inpatientss, it cannot be deemed that this country constitutes a " nurse taking exclusive charge of nursing services" as stated in the public notice of the detailed contents of this case. Thus, in determining the rating for calculating the hospitalization fees in a long-term care hospital according to the point of relative values of this case, this map may not be included in the number of nurses.
Meanwhile, according to the type and content of the provision of the relative value point of this case, the level of nursing workforce by grade is divided according to the number of nursing workforce by the number of sickbeds number, and the number of nursing workforce is increased or decreased depending on the grade, and the number of sickbeds and the number of nursing workforce is calculated according to the number of sickbeds and the number of nursing workforce.
The results of the calculated grade shall not be deemed to have been arbitrarily adjusted, or it shall not be deemed that it is possible to separately determine whether to increase or decrease the prescribed points in hospital admission fees by grade.
Therefore, the disposition of this case, which adjusted the plaintiff's medical care costs by applying the level of securing the plaintiff's medical care costs to six grades as the result of the defendant's finding as the nursing manpower exclusively in charge of providing nursing services to the inpatients, is legitimate, and the court below judged the disposition of this case as unlawful for reasons stated in its holding. Thus, the court below erred in the misapprehension of legal principles as to the point of relative value and the legal nature of the notice of detailed contents, which affected the conclusion of the judgment.
Therefore, without further proceeding to decide on the remaining grounds of appeal, the lower judgment is reversed, and the case is remanded to the lower court. It is so decided as per Disposition by the assent of all participating Justices on the bench.
Justices Park Jae-young
Justices Park Si-hwan
Justices Cha Han-sung
Justices Shin Young-chul
Justices Park Byung-hee