이득금지원칙과 실손의료보험 감면제도의 법적 쟁점에 관한 연구

Abstract

When calculating medical expenses in the field, various reduction/exemption systems such as medical expense reduction/exemption system for meritorious persons and their families, reduction/exemption system for hospital staff, reduction/exemption system for acquaintances, and copay cap system, etc. are operated. Practical disputes are frequently found on whether the reduced/exempted amount by such reduction/exemption systems is subject to applying the principle of prohibition of profits. Especially, the copay cap system causes many disputes recently in relation to medical indemnity insurance. Nevertheless, such disputes and arguments, Financial Disputes Mediation Committee and Consumers Dispute Settlement Commission make conflicting decisions on similar issues because in-depth studies have not been conducted on these issues. This study was conducted on various reduction/exemption systems based on the principle of prohibition of profits and on how to reasonably solve such recent disputes. The principle of prohibition of profits is not prescribed in the law but is recognized as a mandatory provision. In the case of medical indemnity insurance, reduction/exemption system for meritorious persons and reduction/exemption system for medical institutions may violate the principle of prohibition of profits but are reflected in the agreement for acceptance. Cases of dispute mediation and judicial precedents related to the copay cap system state that refunds of the copay cap system is not exempted in case of medical indemnity insurance agreement before a standard agreement in 2009 and such statement is deemed reasonable. Therefore, refunds of the copay cap system would be deemed reasonable in case of the agreement after the standard agreement. However, as the principle of objective interpretation may be violated if the processing method is different by insurance company, it would be required to unify the methods so that insurance money is paid in full without consideration of the copay cap system when payment of insurance is requested and refund is done after the payment of refund money. Also, as insurance benefit belongs to main agreement and insurance non-benefit belongs to the special agreement in the 4th generation medical indemnity insurance, it would be required to basically solve the disputes related to the copay cap system by limiting the maximum insurance amount within the copay cap amount in case of main agreement to guarantee insurance benefit.