Open Decision Ledger · Constitutional, administrative & state liability
Medical Act breach alone does not bar benefit payment or recovery
Supreme Court, May 30, 2019, 2015Du36485 (judgment)
Case name: 진료비지급보류정지처분취소청구(네트워크 의료기관의 요양급여비용 청구 사건)
Official text on the National Law Information Center
Question
May the National Health Insurance Service refuse to pay the medical costs of benefits, or recover the amounts already paid, solely because a licence-holding doctor formally opened the clinic while another doctor who already ran other clinics in fact opened and operated it in breach of Article 33(8) or Article 4(2) of the Medical Act?
Holding
No. The National Health Insurance Act and the Medical Act share the aim of protecting public health, but they do not share their legislative purpose and regulated subject matter, so whether an institution counts as a medical institution opened under the Medical Act must be decided by weighing whether it is suited to providing the benefits the Insurance Act requires. An institution opened in breach of Article 33(8) or Article 4(2) was still opened by a person allowed to open a clinic, and the care its named founder gave cannot be asserted to differ in quality from ordinary care unless it falls below or exceeds the standards for benefits, so that breach alone neither bars payment of the costs of benefits nor makes receipt of them an obtaining by deceit or other improper means.
Summary of the holding, verbatim
그 사정만을 가지고 위 의료기관이 국민건강보험법에 의한 요양급여를 실시할 수 있는 요양기관인 ‘의료법에 따라 개설된 의료기관’에 해당하지 아니한다는 이유로 요양급여에 대한 비용 지급을 거부하거나, 위 의료기관이 요양급여비용을 수령하는 행위가 ‘속임수나 그 밖의 부당한 방법에 의하여 요양급여비용을 받는 행위’에 해당된다는 이유로 요양급여비용 상당액을 환수할 수는 없다.
Unofficial English translation
On the sole basis of such circumstances, one cannot refuse the payment of expenses for medical care benefits on the ground that the said medical institution does not fall under a 'medical institution established pursuant to the Medical Service Act' as a medical care institution capable of providing medical care benefits under the National Health Insurance Act, nor can one recover the amount equivalent to the medical care benefit expenses on the ground that the act of the said medical institution in receiving the medical care benefit expenses constitutes 'an act of receiving medical care benefit expenses by deception or other improper means'.
Disposition
Reversed and remanded Stated in the decision
원심판결을 파기하고, 사건을 서울고등법원에 환송한다.
Unofficial English translation
The judgment of the court below is reversed, and the case is remanded to the Seoul High Court.
Form of the test
Circumstances weighed Stated in the decision
이러한 사정들을 종합하면, 의료인으로서 자격과 면허를 보유한 사람이 의료법에 따라 의료기관을 개설하여 건강보험의 가입자 또는 피부양자에게 국민건강보험법에서 정한 요양급여를 실시하였다면
Unofficial English translation
Taking these circumstances into comprehensive consideration, if a person holding qualifications and a license as a medical professional has established a medical institution pursuant to the Medical Service Act and provided the medical care benefits prescribed in the National Health Insurance Act to subscribers or dependents under health insurance,
Factors
- 국민건강보험법에서 정한 요양급여를 실시하는 기관으로서 적합한지를 고려하여 판단하여야 한다
- 그 의료기관도 의료기관 개설이 허용되는 의료인에 의하여 개설되었다는 점에서는 본질적인 차이가 없고
- 국민건강보험법에서 정한 요양급여의 기준에 미달하거나 그 기준을 초과하는 등의 다른 사정이 없는 한 정상적인 의료기관의 개설자로서 하는 진료행위와 비교하여 질병의 치료 등을 위한 요양급여로서 질적인 차이가 있다고 단정하기 어렵다
- 의료법이 위 각 의료법 조항을 위반하여 의료기관을 개설·운영하는 의료인에게 고용되어 의료행위를 한 자에 대하여 처벌규정을 두지 아니한 것도 이를 고려한 것으로 보인다
Unofficial English translation
• it must be determined by taking into consideration whether it is appropriate as an institution providing the medical care benefits prescribed in the National Health Insurance Act
• there is no essential difference in that the medical institution was also established by a medical professional who is permitted to establish a medical institution, and
• unless there are other circumstances such as the medical institution falling short of or exceeding the standards for medical care benefits prescribed in the National Health Insurance Act, it is difficult to conclude categorically that there is any qualitative difference in medical care benefits for treatment of diseases, etc., compared to medical practice conducted as the establisher of a normal medical institution
• the fact that the Medical Service Act does not contain a penal provision for a person who, having been employed by a medical professional who establishes and operates a medical institution in violation of each of the aforesaid provisions of the Medical Service Act, has engaged in medical practice also appears to have taken this into consideration
Relation to precedent
States a new standard Read from the decision
따라서 국민건강보험법에 의하여 요양기관으로 인정되는 ‘의료법에 따라 개설된 의료기관’의 범위는 이러한 국민건강보험법과 의료법의 차이를 염두에 두고 국민건강보험법에서 정한 요양급여를 실시하는 기관으로서 적합한지를 고려하여 판단하여야 한다.
Unofficial English translation
Accordingly, the scope of 'medical institutions established pursuant to the Medical Service Act' that are recognized as medical care institutions under the National Health Insurance Act must be determined by taking into consideration, keeping in mind such differences between the National Health Insurance Act and the Medical Service Act, whether they are appropriate as institutions providing the medical care benefits prescribed in the National Health Insurance Act.
Decisions referred to
해당 본문 참조
Burden of proof
Not addressed Not in the decision
Open question and revisit condition
Would a refusal or recovery resting on a breach of Article 33(2) of the Medical Act, where Article 90 of that Act punishes a person employed to perform medical acts by an opener who may not open a medical institution, be judged differently?
The judgment of the Seoul High Court on remand, once it re-examines the payment suspension against this standard, will show how the standard is applied. A later Supreme Court decision on the scope of a medical institution opened under the Medical Act, or an amendment to Article 33 or Article 4 of the Medical Act or to the benefit provisions of the National Health Insurance Act, would require this entry to be read again.
Cross-family AI independent reading & axis check
5 of 8 axes matched GPT-6 Astra (OpenAI, codex CLI) · 2026-10-25
A reader from another model family (GPT-6 Astra), given the official text but not the primary reading, agreed on 5 of the 8 axes; the readings differed on axis 4 (form of the test), axis 6 (relation to precedent), axis 8 (open question and revisit condition).
Axis 4 (Form of the test): Primary “Circumstances weighed” vs Independent “Elements stated”
The primary reading treats the standard as a collective weighing of factors, while the independent reading frames it as stated requirements. The operative reasoning is the same, but the form of the test is characterized differently.
그 사정만을 가지고 위 의료기관이 국민건강보험법에 의한 요양급여를 실시할 수 있는 요양기관인 ‘의료법에 따라 개설된 의료기관’에 해당하지 아니한다는 이유로 요양급여에 대한 비용 지급을 거부하거나Axis 6 (Relation to precedent): Primary “States a new standard” vs Independent “Cannot be determined”
The primary reading treats the judgment as setting a new standard, while the independent reading could not confirm a precedent relationship. The two differ on whether the ruling departs from existing case law.
따라서 국민건강보험법에 의하여 요양기관으로 인정되는 ‘의료법에 따라 개설된 의료기관’의 범위는 이러한 국민건강보험법과 의료법의 차이를 염두에 두고 국민건강보험법에서 정한 요양급여를 실시하는 기관으로서 적합한지를 고려하여 판단하여야 한다.Axis 8 (Open question and revisit condition): Primary “Would a refusal or recovery resting on a breach of Article 33(2) of the Medical Act, where Article 90 of that Act punishes a person employed to perform medical acts by an opener who may not open a medical institution, be judged differently?” vs Independent “Under what additional circumstances would deficiencies in the benefits provided justify denying payment or recovering payments already made?”
The primary asks whether a breach of Article 33(2), where Article 90 punishes employed practitioners, would change the result. The independent asks what additional defects in the benefits themselves would justify denial or recovery. These are related but different unresolved points.
그 사정만을 가지고 위 의료기관이 국민건강보험법에 의한 요양급여를 실시할 수 있는 요양기관인 ‘의료법에 따라 개설된 의료기관’에 해당하지 아니한다는 이유로 요양급여에 대한 비용 지급을 거부하거나, 위 의료기관이 요양급여비용을 수령하는 행위가 ‘속임수나 그 밖의 부당한 방법에 의하여 요양급여비용을 받는 행위’에 해당된다는 이유로 요양급여비용 상당액을 환수할 수는 없다.Raw responses and comparison record: Protocol · Blind readings (JSONL) · Axis comparison (JSONL) · SHA-256 (JSON)
Lower-court contrast & scope of application
Lower-court reading vs. Supreme Court holding
Lower-court context: The Seoul High Court, in its judgment of 23 December 2014 (2014Nu57449), held that the payment suspension of 29 January 2014 was lawful. It reasoned that the hospital was not a medical institution lawfully opened and operated under the Medical Act, so it could not provide benefits, the opening name having been changed to the plaintiff's in August 2012 although A ran the hospital in fact and the plaintiff was only a doctor employed by him.
Supreme Court standard: The Supreme Court held that the court below had misapprehended the law governing which institutions may provide benefits under the National Health Insurance Act, in a way that affected the judgment. A licence-holding doctor who obtained the opening permit for the hospital in his own name under the Medical Act and provided benefits to insured or dependent patients may claim the benefit costs, so the suspension could not rest on the hospital being one of the clinics A duplicated. The Court reversed the whole judgment and remanded it to the Seoul High Court, and separately dismissed the applications of the plaintiff's interveners for lack of a legal interest in the outcome, with the costs on them.
Distinguishing conditions
- A medical institution opened by a person who did not hold the qualification and licence of a medical practitioner, since the Court's reasoning rests on the opener being one allowed to open a clinic.
- Care that falls below or exceeds the standards for benefits set by the National Health Insurance Act, which the Court treated as another circumstance capable of showing a difference in quality.
- Costs obtained by deceit or some other improper means, since the decision addressed only refusal or recovery based on the manner of opening.
Record verification notes
Set against the file whether the person who obtained the opening permit held the licence of a medical practitioner and whether the care given met the standards for benefits, since the Court relied on both points. Then confirm which provisions were in force when the benefits were provided and when the suspension was taken, as the decision refers to Article 1, Article 41(1), Article 42(1) and Article 47(1) of the National Health Insurance Act and Article 1, Article 4(2), Article 33(2)(i), Article 33(8) and Article 90 of the Medical Act.
From the official text
Points at issue
의료인으로서 자격과 면허를 보유한 사람이 의료법에 따라 의료기관을 개설하여 건강보험 가입자 또는 피부양자에게 요양급여를 실시하였으나, 이미 다른 의료기관을 개설·운영하는 의료인이 위 의료기관을 실질적으로 개설·운영하였거나 의료인이 다른 의료인 명의로 위 의료기관을 개설·운영함으로써 의료법을 위반한 경우, 그 사정만으로 요양급여에 대한 비용 지급을 거부하거나 수령한 요양급여비용 상당액을 환수할 수 있는지 여부(소극)
Unofficial English translation
Whether, where a person holding qualifications and a license as a medical professional has established a medical institution pursuant to the Medical Service Act and provided medical care benefits to subscribers or dependents under health insurance, but another medical professional who already establishes and operates another medical institution has substantially established and operated the said medical institution, or a medical professional has established and operated the said medical institution in the name of another medical professional, thereby violating the Medical Service Act, the payment of expenses for medical care benefits may be refused or the amount equivalent to the medical care benefit expenses received may be recovered on the sole basis of such circumstances (negative)
Summary of the holding
국민건강보험법과 의료법은 국민보건이나 국민 건강 보호·증진을 위한 법률이라는 점에서는 목적이 같지만, 국민건강보험법은 질병의 치료 등에 적합한 요양급여 실시에 관하여 규정하는 법률임에 비하여, 의료법은 모든 국민이 수준 높은 의료 혜택을 받을 수 있도록 하기 위해 의료인, 의료기관 및 의료행위 등에 관하여 규정하는 법률로서, 입법 목적과 규율대상이 같다고 보기 어렵다. 따라서 국민건강보험법에 의하여 요양기관으로 인정되는 ‘의료법에 따라 개설된 의료기관’의 범위는 이러한 국민건강보험법과 의료법의 차이를 염두에 두고 국민건강보험법에서 정한 요양급여를 실시하는 기관으로서 적합한지를 고려하여 판단하여야 한다. 그리고 비록 의료법 제33조 제8항 본문(중복개설금지 조항), 제4조 제2항(명의차용개설금지 조항)은 의료인이 둘 이상의 의료기관을 개설·운영하는 것 및 다른 의료인의 명의로 의료기관을 개설하거나 운영하는 행위를 제한하고 있으나, 그 의료기관도 의료기관 개설이 허용되는 의료인에 의하여 개설되었다는 점에서는 본질적인 차이가 없고, 또한 그 의료기관의 개설 명의자인 의료인이 한 진료행위도 국민건강보험법에서 정한 요양급여의 기준에 미달하거나 그 기준을 초과하는 등의 다른 사정이 없는 한 정상적인 의료기관의 개설자로서 하는 진료행위와 비교하여 질병의 치료 등을 위한 요양급여로서 질적인 차이가 있다고 단정하기 어렵다. 의료법이 위 각 의료법 조항을 위반하여 의료기관을 개설·운영하는 의료인에게 고용되어 의료행위를 한 자에 대하여 처벌규정을 두지 아니한 것도 이를 고려한 것으로 보인다. 이러한 사정들을 종합하면, 의료인으로서 자격과 면허를 보유한 사람이 의료법에 따라 의료기관을 개설하여 건강보험의 가입자 또는 피부양자에게 국민건강보험법에서 정한 요양급여를 실시하였다면, 설령 이미 다른 의료기관을 개설·운영하고 있는 의료인이 위 의료기관을 실질적으로 개설·운영하였거나, 의료인이 다른 의료인의 명의로 위 의료기관을 개설·운영한 것이어서 의료법을 위반한 경우라 할지라도, 그 사정만을 가지고 위 의료기관이 국민건강보험법에 의한 요양급여를 실시할 수 있는 요양기관인 ‘의료법에 따라 개설된 의료기관’에 해당하지 아니한다는 이유로 요양급여에 대한 비용 지급을 거부하거나, 위 의료기관이 요양급여비용을 수령하는 행위가 ‘속임수나 그 밖의 부당한 방법에 의하여 요양급여비용을 받는 행위’에 해당된다는 이유로 요양급여비용 상당액을 환수할 수는 없다.
Order
원심판결을 파기하고, 사건을 서울고등법원에 환송한다. 원고 보조참가인들의 보조참가신청을 각하한다. 보조참가로 인한 소송비용은 원고 보조참가인들이 부담한다.
Unofficial English translation
The judgment of the court below is reversed, and the case is remanded to the Seoul High Court. The applications for auxiliary intervention filed by the plaintiff's auxiliary intervenors are dismissed on procedural grounds. The litigation costs arising from the auxiliary intervention shall be borne by the plaintiff's auxiliary intervenors.
Provisions referred to
국민건강보험법 제1조, 제41조 제1항, 제42조 제1항, 제47조 제1항, 의료법 제1조, 제4조 제2항, 제33조 제2항 제1호, 제8항, 제90조
Read 2026-10-25 · Cross-read 2026-10-25. All quotes matched against the official text. The Chinese-character placeholders the court used for anonymised parties are given in their Korean readings, and parenthetical Chinese-character glosses are omitted.
Every entry is published only after all quotes have been matched character by character against the official text, and audited by an independent second reading from a different model family across all eight axes. Both agreed axes and text-grounded interpretive divergences are recorded openly. The ledger is a research record, not an assessment of the court or advice on any matter.
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