Supreme Court Decision 2020Du36052 Decided October 15, 2020【Revocation of Disposition of Recovering Health Care Benefits, etc.】

[1] In a case where a health care institution established under the National Health Insurance Act provided health care benefits in violation of other individual administrative laws including the Emergency Medical Service Act and was reimbursed with the costs of health care benefits, whether such a case falls within the case involving a “health care institution that has received insurance benefit costs by fraud or other improper means,” stipulated in Article 57(1) of the former National Health Insurance Act, that is subject to the collection of unjust enrichment or unjust profit

[2] In the case where: (a) Hospital A, designated as a local emergency medical institution, failed to satisfy the personnel requirements that there must be five or more nurses exclusively responsible for an emergency unit, as stipulated in [Addendum 8] entitled “Standards for Appointment of Local Emergency Medical Institution” of the Enforcement Regulation of Emergency Medical Service Act; (b) Hospital A nonetheless continued to provide emergency care to walk-in patients in the emergency unit and was reimbursed with emergency medical service fees; and (c) the National Health Insurance Service imposed a disposition of collecting emergency medical service fees on Hospital A for having received a reimbursement of emergency medical service fees by fraud or other improper means, the case holding that, insofar as Hospital A did provide emergency care to walk-in patients to the emergency unit, the emergency medical service fees Hospital A was reimbursed with in relation to the aforementioned emergency care provided are difficult to be considered as falling within the “health insurance benefit costs received by fraud or other improper means,” stipulated in Article 57(1) of the former National Health Insurance Act, that are subject to the collection of unjust enrichment or unjust profit, based solely on the circumstance that Hospital A failed to satisfy the personnel standards for emergency unit nurses