[1] The relationship between the revocation of designation as a medical care institution under the former Medical Insurance Act and the former Medical Insurance Act for Public Officials and Private School Teachers and Staff

[2] The scope of "insurance benefit costs have been received by deceit or other unlawful means" under Article 45 (1) of the former Medical Insurance Act and the former Medical Insurance Act for Public Officials and Private School Teachers and Staff

[1] Articles 32 and 33 of the former Medical Insurance Act (amended by Act No. 5453, Dec. 13, 1997); Articles 33 and 34 of the former Public Officials and Private School Teachers and Staff Medical Insurance Act (repealed by Article 2 of the Addenda to the National Medical Insurance Act, Act No. 548, Dec. 31, 1997); and Article 3 [Attachment Table 1] of the former Guidelines for Revocation of Designation of Medical Insurance (repealed by the Ministry of Health and Welfare, No. 197-66, Aug. 30, 197) of the Ministry of Health and Welfare’s guidelines for cancellation of designation; if an order for cancellation of designation becomes final and conclusive based on the initial guidelines for cancellation of designation; if an order for cancellation of designation becomes final and conclusive based on the guidelines for cancellation of designation; and if an order for cancellation of designation becomes final and conclusive based on the guidelines for cancellation of designation as well as other guidelines for cancellation of designation, the same shall not apply to the relevant administrative disposition.

[2] Article 45 (1) of the former Medical Insurance Act (amended by Act No. 5453 of Dec. 13, 1997) and Article 45 (1) of the former Medical Insurance Act (amended by Act No. 5488 of Dec. 31, 1997) of the Public Officials and Private School Teachers and Staff Medical Insurance Act (repealed by Article 2 of the Addenda to the National Medical Insurance Act, Act No. 5488 of Dec. 31, 1997) provide that "the insurer or the insurer's organization shall collect all or part of the amount equivalent to the insurance benefits costs from the medical care institution that received the insurance benefits costs by deceit or other unlawful means." Here, the "insurance benefits costs were paid by the medical care institution in violation of the medical care benefits standard (Notice of the Ministry of Health and Welfare No. 1995-58 of the Ministry of Health and Welfare), the medical care benefits standard (Notice of the Ministry of Health and Welfare No. 1995-5 of the Ministry of Health and Welfare).

[1] Article 32 of the former Medical Insurance Act (amended by Act No. 5453, Dec. 13, 1997; see Article 40 of the current National Health Insurance Act); Article 33 (see Article 40 of the current National Health Insurance Act); Article 34 (see Article 40 of the current National Health Insurance Act); Article 34 (see Article 40 of the current National Health Insurance Act); Article 15 of the former Medical Insurance Act (amended by Act No. 5454, Mar. 13, 1996; Article 3 [Attachment 1] [Attachment 2] (Article 40 of the former Public Health Insurance Act; Article 40 of the current National Health Insurance Act; Article 5(1) of the former Medical Insurance Act (amended by Act No. 5454, Dec. 31, 1997; see Article 19-6(1) of the former Public Health Insurance Act (amended by Act No. 15328, Apr. 19, 1997); Article 25 of the former Public Health Insurance Act (Public Health Insurance Act)

[1] Supreme Court Decision 93Nu12619 delivered on December 10, 1993 (Gong1994Sang, 374)

Plaintiff (Law Firm Sang, Attorneys Seo-ok et al., Counsel for the plaintiff-appellant)

The National Compensation Insurance Management Corporation and one other (Law Firm Bag, Attorneys Noh Jeong-eng et al., Counsel for the defendant-appellant)

Seoul High Court Decision 97Gu47615 delivered on February 11, 1999

Of the judgment below, the part of the claim for revocation of designation of medical insurance medical care institution (including the disposition prohibiting re-designation) is reversed, and that part of the case is remanded to the Seoul High Court. With respect to the claim for revocation of restitution of unjust enrichment among the judgment below, the appeal is dismissed. The costs of appeal

1. Regarding the disposition to revoke the designation of the medical insurance medical care institution of this case (hereinafter referred to as the "disposition to revoke the designation"), (current changes into the business suspension under the National Health Insurance Act and became the authority of the Minister of Health and

A. The court below determined that the disposition of revocation of the designation and the disposition of prohibition of re-designation of this case that the Public Officials and Private School Teachers and Staff Medical Insurance Management Corporation (hereinafter referred to as the "Public Service") and the Medical Insurance Federation (hereinafter referred to as the "Federation") and the Medical Insurance Association (hereinafter referred to as the "Federation") decided that the lawsuit of revocation of designation and the lawsuit of revocation of re-designation of this case is dismissed as unlawful on the ground that the plaintiff's act of guiding the payment of monetary substitution charges in lieu of the cancellation of designation is not effective as an administrative disposition which directly affects the rights and obligations of the people because there are no legal grounds for any change in the act of guiding the payment of money substitution charges in lieu of the cancellation of designation of medical care institutions, and its contents cannot be seen as an administrative disposition that can be seen as an administrative disposition.

B. Articles 32 and 33 of the former Medical Insurance Act (amended by Act No. 5453, Dec. 13, 1997; hereinafter referred to as the "Act") and Articles 33 and 34 of the former Act on the Medical Insurance for Public Officials and Private School Teachers and Staff (amended by Act No. 548, Dec. 31, 1997; hereinafter referred to as the "Public Medical Insurance Act") provide that the designation of medical care institutions and the cancellation thereof shall be respectively. Accordingly, the former standards for revoking designation of medical care institutions (amended by Act No. 15453, Mar. 13, 1996; hereinafter referred to as the "Act") stipulate that the designation of the medical care institutions shall be cancelled in lieu of the new payment regulations, Article 3 of the former Act on the Medical Insurance for Public Officials and Private School Teachers and Staff (amended by Act No. 5486, Dec. 31, 1997; hereinafter referred to as the "standard for revoking designation" shall be determined as the new payment regulations.

In full view of the above relevant provisions, if the insurer gives notice of the scheduled disposition of cancellation in order to give an opportunity to state opinions to the relevant medical care institution prior to the disposition of cancellation, it shall be deemed that it is merely a notification of simple concept, not an administrative disposition subject to appeal litigation, but a simple disposition of cancellation in order to give an opportunity to state opinions. However, if the insurer gives notice of the scheduled disposition of cancellation in accordance with Articles 3 and 4 of the following criteria, as well as the reasons for the disposition, the initial date of the disposition of cancellation, the initial date of the disposition of cancellation, the period of prohibition of re-designation, the number of money substitutions, etc., which is the effective date of the disposition of cancellation, are indicated as the notice of expected cancellation, and if the insurer receives the permission before the base date of cancellation, it shall be deemed that the disposition of cancellation is reserved, even though the medical care institution fails to select and receive the money substitutions on the 9th day of cancellation without a separate disposition of cancellation, and it shall not be deemed that the payment of money substitutions becomes effective as the initial disposition of cancellation without delay.

C. According to the records, the Federation and the Public Educational Service conducted an investigation into unjust enrichment on September 14, 1996 (the target period: March 1, 1995; May 31, 1995; and October 1 through 31, 1995; and December 31, 1995; and the Minister of Health and Welfare issued instructions on the cancellation of designation to the Federation and the Public Educational Service for ten months until July 19, 197; notified the Plaintiff of the contents of unjust enrichment amount and unfair rate; the re-designation prohibition period for the cancellation of designation; the amount of money substitution; the reason for the cancellation of designation; the basis for the cancellation of designation; and the period for the cancellation of designation; and the period for the cancellation of the designation of the Federation and did not inform the Plaintiff of the determination to the extent that the payment was not made in installments; and it did not inform the Plaintiff of the determination to the extent that the payment was not made in full or in full in accordance with Article 3.

D. Therefore, the revocation of the designation made by the Federation on July 25, 1997 and the scheduled notification of the revocation of designation made on July 30, 1997 by the Public Service and Private School Corporation on July 30, 1997 are effective on the date of revocation of designation. However, the calculation of the period of prohibition of re-designation and the initial date thereof may be determined differently depending on whether the payment of money in installments is permitted, and thus, it constitutes a revocation of designation, which is an administrative disposition subject to appeal litigation. Thus, the court below erred in the misapprehension of legal principles as to the revocation of designation and administrative disposition (in addition, the indication of the period of prohibition of re-designation is not a separate disposition, but an indivisible one, separate from the revocation of designation, but it shall be pointed out that the court below erred that it is a separate disposition).

2. On the disposition of restitution of unjust enrichment in this case (currently became the authority of the defendant National Health Insurance Corporation under the National Health Insurance Act)

A. misunderstanding of the legal principles under Article 45(1) of the Act and the Public Offering and Private School Act

Article 45 (1) of the Act and the Public Offering and Security Act provides that "the insurer or the insurer's organization shall collect all or part of the amount equivalent to the expenses for insurance benefits from a medical care institution which has received the expenses for insurance benefits by deceit or any other unlawful means." Here, "the expenses for insurance benefits have been paid by deceit or any other unlawful means" means that the medical care institution violates the medical care benefit standard (Notice of the Ministry of Health and Welfare No. 1995-58, hereinafter referred to as "medical care benefit standard") and the medical care fees standard (Notice of the Ministry of Health and Welfare No. 1995-55, hereinafter referred to as "the medical care fees standard") in excess of the expenses for insurance benefits from the insurer, the insurer's organization, or the insured, not only is the case where the medical care institution arbitrarily conducts non-benefit medical treatment without complying with the medical care benefit standard and the medical care institution agrees to be an insurance expense between the person who received the medical care institution and the person who received the medical expenses.

The judgment of the court below to the same purport is just, and there is no error in the misapprehension of legal principles as to Article 45 (1) of the Act, and Article 45 (1) of the Public Officials and Education Act. The ground for appeal otherwise

(b) Violation of the rules of evidence against the Rayer's material costs, special powder price, physical exercise costs, higher-ranking soldiers' fees, etc.

(1) Summary of the judgment below

Based on adopted evidence, the court below found that the plaintiff, while conducting a procedure using the CO2 (CO2) Malaysia, he pretended to perform the operation and received the materials from the patients, and received the full amount of medicine from the patients as if he did not administered the imported dystrophys, such as beer, without administering them to the patients. The plaintiff's management was provided with physical therapy using the physical therapy equipment such as low-frequency therapy in our gysium, and the patient was kept separately from the patient's own dystros operated by the Korean vertebrate Health Research Institute in Korea, the non-party corporation, without being equipped with the standard beds under the Medical Service Act, and received higher-ranking illness fees from the patients without being equipped with the standard beds under the Medical Service Act, which constitutes "the case where he received the insurance benefit costs by means of death or other unlawful means" under the Act and Article 45 of the Public Health and Security Act.

(2) Determination as to the Rayer's operating materials

According to the records, the plaintiff was deemed to have received materials for insurance expenses from patients during the period of the on-site investigation from March 1, 1995 to May 31, 1995, as if he had performed the CO2 radar operation, but was pretended to have performed the on-site operation, and did not have received materials from patients. However, during that period, the plaintiff did not undergo the CO2 radar operation, the lusium operation, or the lusium lusium laplate operation (OLM, openla, 427-431, etc.) and received materials for insurance expenses from patients (Records 305-312, 427-431, etc.) but it was not permitted to receive materials separately from patients other than the operation expenses, and even if it was revised by the 4th guidelines and other guidelines related to medical fees before the enforcement date of the above on-site investigation, the above rasium operation cannot be applied to the patient's insurance benefits guidelines, as stated in its reasoning.

Therefore, the fact-finding that the court below found that the plaintiff had received materials from the patient by pretending that the plaintiff had performed the CO2 radar operation even after the plaintiff performed the operation, is erroneous, but the error did not affect the conclusion of the judgment and did not err in the rules of evidence or the rule of experience in the judgment of the court below as to this part.

(3) Determination on remaining points

Examining the reasoning of the judgment of the court below in light of the relevant statutes and the records, all of the findings and judgments of the court below on this part are justified, and there is no violation of the rules of evidence or the rules of experience.

3. Therefore, the part of the judgment of the court below regarding the claim for revocation of the revocation of designation (including the disposition prohibiting re-designation) is reversed, and that part of the case is remanded to the court below for further proceedings consistent with this Opinion. The appeal regarding the claim for revocation of the unjust enrichment is dismissed. It is so decided as per Disposition by the assent

Justices Yoon Jae-sik (Presiding Justice)