국민건강보험법상 임의비급여 진료비 부당이득반환채권에 대한 보험회사의 채권자대위 가능성 - ‘트리암시놀론 주사’ 사건과 ‘맘모톰 절제술’ 사건을 중심으로 -

Abstract

If a medical institution's medical practice to a patient is not listed on the benefit coverage or statutory non benefit coverage under the National Health Insurance Act, the medical practice is a arbitrary non-benefit coverage that has not been approved for safety and effectiveness. In principle, it cannot perform the medical practice on the patient and of course cannot receive medical expenses. These arbitrary non-benefits coverage are not covered by private medical expense insurance. The court's basic position on arbitrary non-benefit coverage treatment and receipt of medical expenses is said to be invalid as a violation of compulsory laws unless there are special circumstances. The Supreme Court interprets that the receipt of medical expenses is valid if several conditions are met even for arbitrary non-benefit coverage medical treatment. It is difficult to say that there was sincere consent from the patient in the target judgment in this paper, and it is difficult to find the inevitability or urgency of implementing arbitrary non-benefit coverage medical practices without implementing other medical practices listed on the benefit coverage or statutory non-benefit coverage list. Therefore, the conditions proposed by the Supreme Court were not met, and the arbitrary non-benefit coverage treatment act is interpreted as illegal. The patient will have a claim to return unfair gains from the medical institution, and if the patient receives insurance money equivalent to medical expenses from the private medical expense insurance company, the insurance company will have the right to claim the return of unfair gains from the patient. At this time, there is a question of whether an insurance company can exercise the unjust enrichment claim of medical expenses that the patient has against the medical institution to satisfy his/her claim. The Supreme Court recently determined that it was impossible for insurers to exercise their subrogation rights to medical institution. As a basis, it is cited that the debtor is insolvent and that the insurance company can individually exercise the right to claim the return of insurance money against the insured(patient). However, the debtor's incapacity requirement is not necessarily required at a time when the purpose of exercising the creditor's subrogation right is changing from the preservation function of the responsible property to a means of realizing the creditor's rights. In addition, it is clear that insurance companies cannot freely file a lawsuit against their customers for the return of insurance money due to regulations by financial regulators. Insurance companies that fail to recover insurance money even after paying insurance money for arbitrary non-benefit coverage will suffer disadvantages such as a rise in the loss rate, which will eventually lead to an increase in insurance premiums. It is unfair to allow medical institutions that have performed arbitrary non-benefit coverage treatment activities that are not allowed to keep medical expenses as they are. Under these circumstances, subrogation right of creditors should be allowed to insurance companies.