자동차보험진료수가 심사위탁에 관한 소고 -자배법 제12조의 2를 중심으로-

Abstract

The National Assembly of Korea established the Clause 2(Assessment Contract), Article 12, by revising the Motor Vehicle Compensation Guarantee Act in part on Nov. 29, 2011. The purpose of the new Clause 2, Article 12 of Motor Vehicle Compensation Guarantee Act was “to prevent leakage of insurance benefits and improve the medical service quality by strengthening specialty, objectivity and fairness of the medical charge assessment for auto insurance through the medical charge assessment contract with the Health Insurance Review and Assessment Service, the professional assessment institution, because of serious leakage of insurance money by false and excessive medical examination and insurance fraud.”The legal status of Health Insurance Review and Assessment Service in accordance with Motor Vehicle Compensation Guarantee Act is the contractor for medical charge assessment with the insurers. In other words, when an insured causes a car accident and a medical institution requests the medical charge after taking care of that insured, the Health Insurance Review and Assessment Service assesses if the medical treatment is appropriate for treatment details, determines the medical charge and notifies it to the medical institution. The Health Insurance Review and Assessment Service is the contractor of insurers which does the businesses related to assessment and claims executed by the insurers in the past. The system which an objection against medical charges determined by the Health Insurance Review and Assessment Service, the assessment contractor, is made and the final means is the legal action in a court when such objection is not accepted is very unfair treatment for medical institutions in terms of fairness and equity. Accordingly, the insurers shall prevent any objections against the assessment results by the Health Insurance Review and Assessment Service, their contractors for assessment to which they pay the fees. If it is considered that the assessment results by the Health Insurance Review and Assessment Service is unfair, it is required to revise the provisions of Article 19 (Assessment Request on Medical Charge of Auto Insurance and Others), Motor Vehicle Compensation Guarantee Act, to enable the medical institutions to request the assessment to Auto Insurance Council for the equity between insurers and medical institutions.