비의료인 개설 병원 의료비에 대한 보험금 지급의무 - 대법원 2018. 5. 15. 선고 2018도1299 판결을 중심으로 -

Abstract

When hospitals established by non-medical personnel issued relevant documents for insurance benefit to their patients, the Supreme Court found the hospital not guilty of fraud. I compared and analyzed this judgment to similar cases that deal with claims for the National Health Insurance Service’s medical care benefits or claims for private health insurance benefits related to hospitals established by non-medical personnel or doctors who borrowed others’ licenses. The court ruled that the crime of fraud was established in the hospital's claim for medical care benefits to the National Health Insurance Service. In contrast, the insurance claim for the private insurance company did not constitute a crime of fraud because there was no deception of fraud. Since the nature and the policies of those two insurances are different, it cannot be said that the precedents are unreasonably discriminating between the National Health Insurance Corporation and the private insurance company concerning the fraud. In this private health insurance benefit claim case, the prosecutor did not file a prosecution for triangular fraud crimes, so the question of the nature of simple fraud. The court denied the establishment of the crime of simple fraud. It is necessary to examine whether “not notifying” the patient and the insurance company that the hospital was not established under the Medical Service Act constitutes the deception of the fraud crime. Considering the scope of application and legislative purpose of the provisions prohibiting the establishment of hospitals by non-medical personnel under the Medical Service Act, the insurance contract between the patient and the insurance company is valid, and the hospital does not have a guarantor's status that bears the duty to notify patients or insurance companies of the facts. Even if a prosecution has been filed for the crime of ‘Dreiecksbetrug’, it cannot be considered that the hospital in charge of notifying ‘the patient’ that it is a hospital established in violation of the Medical Service Act and not issuing related documents does not meet the requirements for the deception of fraud. It is the same as in the case of simple fraud. Therefore, this judgment is a judgment that does not lose the equity between the case claiming medical care benefit expenses and the case of a private insurance company. There is no error in the judgment on deception, a requirement for fraud.