[1] Whether the National Health Insurance Corporation may seek a return of unjust enrichment equivalent to the costs of health care benefit paid pursuant to the above decision against the health care institution without revoking the decision to pay the costs of health care benefit (negative in principle)

[2] In a case where a person who is not qualified to establish a medical institution receives medical care benefit, constitutes a tort, whether the scope of compensation for damages can be limited by considering the offsetting of profit and loss or by applying the equitable principle (affirmative), and whether the responsibility of the person who established the medical institution may vary from the responsibility of the person who established the medical institution (affirmative)

[1] Articles 47, 87, 88, and 90 of the National Health Insurance Act; Article 741 of the Civil Act / [2] Articles 393, 396, 750, 763 of the Civil Act; Article 57 (1) of the National Health Insurance Act

[1] Supreme Court Decision 2013Du6541 Decided April 26, 2017 / [2] Supreme Court Decision 2012Da91262 Decided June 13, 2013 (Gong2020Ha, 1367), Supreme Court Decision 2015Du3996 Decided June 4, 2020 (Gong20Ha, 1367), Supreme Court Decision 2018Du44838 Decided July 9, 2020 (Gong20Ha, 1609)

National Health Insurance Corporation (Attorney Jeong-won et al., Counsel for the plaintiff-appellant)

Defendant 1 and four others (Bae, Kim & Lee LLC et al., Counsel for the defendant-appellant)

Seoul High Court Decision 2014Na2051808 decided June 12, 2015

All appeals are dismissed. The costs of appeal are assessed against the Plaintiff.

The grounds of appeal are examined.

1. As to the assertion of misapprehension of legal principles as to unjust enrichment (ground of appeal No. 1)

A. According to the National Health Insurance Act, the health care institution shall make a request for review of the health care benefit costs to the Health Insurance Review and Assessment Service, and the request for review shall be considered as the claim for the health care benefit costs for the National Health Insurance Corporation (hereinafter “Corporation”), and the Health Insurance Review and Assessment Service shall immediately notify the Service and the health care institution of the details of the review, and the Corporation notified of the details of the review shall, without delay, pay the health care benefit costs to the health care institution (Article 47). A person who is dissatisfied with the Service’s disposition on the cost of insurance benefits (Article 87), a person dissatisfied with the decision on the objection may file an objection with the Health Insurance Dispute Mediation Committee under the Ministry of Health and Welfare (Article 88), and a person who

B. According to the provisions on the procedures for the payment and objection of medical care benefit costs, the claim for medical care benefit costs to the Corporation is specific rights by the Corporation upon the request of a medical care institution, or by the National Health Insurance Act, regardless of the Corporation’s decision. Therefore, if a decision on the payment of medical care benefit costs corresponding to the legal cause of the receipt of medical care benefit costs by a medical care institution has not been revoked, it cannot be deemed that the medical care benefit costs paid according to such decision are gains without any legal cause, unless there are special circumstances such as that the decision on the payment of medical care benefit costs is null and void automatically, and it does not constitute a claim for the return of unjust enrichment equivalent to the medical care benefit costs by the Corporation (see, e.g., Supreme Court Decision 20

C. Examining the reasoning and records of the judgment below in light of the aforementioned legal principles, there is no assertion or evidence that the Plaintiff voluntarily revoked the decision to pay the medical care benefit cost of this case, and there is no circumstance to deem the decision to pay the medical care benefit cost of this case null and void per annum, and thus, the Plaintiff’s right to claim restitution of unjust enrichment cannot be deemed to be established. The reasoning of the judgment below that there is insufficient evidence to acknowledge whether the Defendants actually accrued profit is inappropriate, but the conclusion to dismiss

2. As to the assertion of misapprehension of legal principles as to the Defendants’ debt relations (Ground of appeal No. 2)

The lower court acknowledged the Defendants’ liability for damages, and clearly determined that the Defendants’ liability was quasi-joint and several liability by using the expression “each party” as to the Defendants’ obligation relationship in the text of the judgment. This part of the grounds of appeal purporting that the lower court determined the nature of obligation as a pro rata obligation

3. As to the assertion of misapprehension of legal principles as to limitation of liability for damages (ground of appeal No. 3)

A. It is not allowed for a person who intentionally committed a tort by taking advantage of the victim’s negligence to claim to reduce his/her liability on the ground of the victim’s negligence. This is because, in cases where such intentional tort falls under an acquisition act, it would result in a result contrary to the principles of equity or good faith by having the perpetrator ultimately possess profits arising from the tort if the restriction on liability, such as offsetting negligence, is recognized. Thus, even in cases of intentional tort, if the aforementioned result is not caused, it is possible to limit liability based on the comparative negligence or the principle of equity (see, e.g., Supreme Court Decisions 2006Da16758, 1675, Oct. 25, 2007; 2013Da76437, Sept. 4, 2014).

B. Even if a medical institution established by a non-qualified medical institution for the establishment of a medical institution constitutes a tort, the scope of compensation for damages may be limited in light of the ideology of the compensation system that equitable apportionment of damages, taking into account all the circumstances such as the circumstance or motive leading up to the act of the medical institution, the objective circumstance involved in the Plaintiff’s damage, and the existence of profit gained by the medical institution (see, e.g., Supreme Court Decision 2012Da91262, Jun. 13, 2013). Furthermore, unjust enrichment collection under Article 57(1) of the National Health Insurance Act, which is an administrative disposition recovering medical care benefits from a person who received insurance benefits or a medical institution that received insurance benefit costs, is a discretionary act, and the medical institution’s content and amount of medical care benefit costs, the role and illegality of the person who established the medical institution and the actual founder in the process of establishing and operating the medical institution, and the degree of profit gained by the person who established the medical institution.

C. Even in cases where a person liable to compensate fails to make a claim on the grounds for limiting the amount of compensation for damages, where the said grounds are acknowledged by the litigation data, the court shall ex officio deliberate and determine it (see, e.g., Supreme Court Decision 2012Da91262, Jun. 13, 2013). Meanwhile, determination of the fact-finding or ratio on the grounds for comparative negligence or limitation of liability in a tort compensation case constitutes the exclusive authority of the fact-finding court in principle, but it is not illegal if it is deemed considerably unreasonable in light of the principle of equity (see, e.g., Supreme Court Decisions 2013Da76437, Sept. 4, 2014; 2013Da85172, Sept. 30, 2016).

D. According to the reasoning of the lower judgment and the evidence duly admitted by the lower court, given that there are no circumstances to deem the instant medical care benefit to be in violation of the standards for medical care benefits, a large number of patients who received the medical care benefits receive medical care benefits similar thereto in other medical care institutions even if the Defendants did not provide the medical care benefits, and in such a case, the Corporation is bound to pay the relevant medical care benefits, etc. In addition, most of the medical care benefits paid by the Plaintiff is appropriated for the expenses actually paid by the Defendants for the provision of medical care benefits, and the considerable portion of the benefits relating to the medical care benefits is considered to have been ultimately attributed to the subscribers, etc. The substantial damages suffered by the Plaintiff cannot be ruled out that there is a probability that the Defendants would not significantly affect the medical care benefits paid by the Defendants. Nevertheless, if the Defendants are liable for the partial damages, such circumstance may bring about a

It is reasonable for the court below to limit the defendants' liability for damages on the grounds of its ruling, but all of the defendants' liability ratios to be recognized as 80% is to be calculated excessively without considering the circumstances to be considered in calculating the damages liability ratio. However, in the instant case where only the plaintiff appealed, the judgment of the court below cannot be reversed and the judgment of the court below cannot be sentenced more disadvantageous to the plaintiff. Thus, the above error by the court below does not affect the conclusion of the judgment.

4. 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 Noh Jeong-hee (Presiding Justice)