국민건강보험법상 ‘임의 비급여 진료행위’의 부당성

Abstract

This is a commentary on the Supreme Court en banc Decision 2010Du27639, 2010Du27646 decided June 18, 2012 which held as to whether, in treatment area not constituting the non-reimbursable treatment area (so-called, legally non-reimbursable treatment act) under the Act and statutes, the act of a medical care institution treating health insurance member or dependents against the medical care payment criteria, etc. and collecting expenses from members, etc. (so-called, voluntary non-reimbursable treatment act) constitutes “collecting medical care payment expenses from, or assessing them on member, etc. by fraudulent or any other unjust means” as an element of the disposition of unjust enrichment collection or suspension of business of medical care institution under the National Health Insurance Act. The Supreme Court examined national health insurance system's purpose, and the National Health Insurance Act and statutes system, etc. It held that 「medical care institution shall provide a medical care payment to members, etc., barring legally non-reimbursable treatment act, according to the criteria and procedure of medical care payment under the Act and statutes in principle; it shall follow criteria and procedure under the Act and statute in collecting medical care payment expense from insurer and member, etc.; and the voluntary non-reimbursable treatment act violates the criteria and it constitutes in principle “fraudulent or any other unjust means.”」Nonetheless, the Supreme Court recognized the exceptions in light of medical practitioner's best treatment duty under the medical law and treatment contract and the patient's right to receive a proper treatment. And it held as criteria for exceptions that a medical care institution has to show procedural issues coordinating irrational medical care payment criteria, etc. rationally, medical care institution's medical need for such treatment beyond the medical care payment criteria, etc., explanation and consent received from member, etc. and it bears the burden of proving them. By this decision, it overruled a precedent holding voluntary non-reimbursable treatment acts without exception as unjust (The Supreme Court Decision 2006Du10368, June 15, 2007, etc.). The judgment of this case can be evaluated to reflect a medical reality where, with maintenance of existing national health insurance system, during the process of medical care institution doing its best in treatment, it collects expenses from patient outside of the health insurance framework. The Supreme Court recognized exceptional permission of voluntary non-reimbursable treatment act and presented its criteria. Thus, the court's burden for hearing and deciding related issues has increased. More specific decision criteria as to voluntary non-reimbursable treatment act's exception criteria are expected to be formed in the future through the parties' dispute, fact-finding, and specific case holdings.