An unreported group cafeteria as unfair means of receiving insurance benefits

1. 01Question

   When a medical institution breaches another individual administrative statute and yet provides medical care benefits and receives the benefit costs, how is it decided whether that falls within 'obtaining insurance benefit costs by deceit or other improper means' under Article 57(1) of the former National Health Insurance Act, and does an unreported group cafeteria alone make the meal charges received by the institution such a case?

2. 02Holding

   Whether the breach of another individual administrative statute counts as deceit or other improper means is decided with the difference in legislative purpose and regulated subject in mind, weighing the content and purpose of the benefit standards under the National Health Insurance Act and whether recovery is needed and to what degree beyond the sanctions that statute provides. The benefit rules pay for meals meeting the personnel and facility standards of the Food Sanitation Act so that institutions give patients hygienic meals suited to treatment, not so that the report of a group cafeteria is obtained. Since a fine of up to KRW 5 million already applies to the unreported operation of a group cafeteria, where the institution provided insured persons or their dependents with patient meals meeting the personnel and facility standards of the Food Sanitation Act, the meal charges it received as meal costs are not obtained by deceit or other improper means.

   Summary of the holding, verbatim

   따라서 요양기관이 건강보험의 가입자 또는 피부양자에게 식품위생법상의 인력·시설 기준을 갖추어 환자 식사를 제공하였다면, 비록 집단급식소 설치신고를 하지 않은 상태에서 식사가 제공되었다고 하더라도 요양기관이 식대 관련 요양급여비용을 수령하는 행위가 ‘속임수나 그 밖의 부당한 방법에 의하여 요양급여비용을 받는 행위’에 해당된다고 볼 수는 없다.

   Unofficial English translation

   Therefore, if a medical institution has provided meals to subscribers or dependents of health insurance in compliance with the personnel and facility standards under the Food Sanitation Act, then, even though the meals were provided without having filed a report on the establishment of a collective feeding facility, the receipt of meal-related medical care benefit expenses by the medical institution cannot be regarded as falling within 'an act of receiving medical care benefit expenses by deception or other improper means.'

3. 03Disposition

   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.

4. 04Form of the test

   Circumstances weighed Stated in the decision

   국민건강보험법령상 보험급여기준의 내용과 취지 및 다른 개별 행정법률에 의한 제재수단 외에 국민건강보험법상 부당이득징수까지 하여야 할 필요성의 유무와 정도 등을 고려하여 판단하여야 한다.

   Unofficial English translation

   It must be determined by taking into account the content and purport of the insurance benefit standards under the National Health Insurance Act and its subordinate statutes, and whether and to what extent there is a need to go so far as to effect recovery of unjust enrichment under the National Health Insurance Act in addition to the punitive measures under other individual administrative statutes.

5. 05Factors

   • 국민건강보험법과 다른 개별 행정법률의 입법 목적 및 규율대상의 차이를 염두에 두고
   • 국민건강보험법령상 보험급여기준의 내용과 취지 및 다른 개별 행정법률에 의한 제재수단 외에 국민건강보험법상 부당이득징수까지 하여야 할 필요성의 유무와 정도 등을 고려하여 판단하여야 한다.
   • 요양기관으로 하여금 환자의 치료에 적합한 위생적인 식사를 제공하게 하려는 데 있는 것이지, 집단급식소의 설치·운영에 대한 신고까지 달성하기 위한 데 있는 것이라고 볼 수는 없다
   • 식품위생법 규정에 따라 과태료를 부과하는 제재를 하는 외에 요양급여비용으로 수령한 식대까지 국민건강보험법상 부당이득징수의 대상으로 보아야 할 정도의 공익상 필요성을 인정하기도 어렵다
   • 요양기관이 건강보험의 가입자 또는 피부양자에게 식품위생법상의 인력·시설 기준을 갖추어 환자 식사를 제공하였다면

   Unofficial English translation

   • Bearing in mind the differences in the legislative purposes and objects of regulation between the National Health Insurance Act and other individual administrative statutes, and

   • it must be determined by taking into account the content and purport of the insurance benefit standards under the National Health Insurance Act and its subordinate statutes, and whether and to what extent there is a need to go so far as to effect recovery of unjust enrichment under the National Health Insurance Act in addition to the punitive measures under other individual administrative statutes.

   • is intended to have medical institutions provide hygienic meals suitable for the treatment of patients, and cannot be regarded as being intended to accomplish even the reporting of the establishment and operation of a collective feeding facility

   • it is also difficult to recognize a public interest necessity of such a degree that, in addition to imposing a fine as a sanction under the provisions of the Food Sanitation Act, the meal expenses received as medical care benefit expenses should be regarded as the subject of recovery of unjust enrichment under the National Health Insurance Act

   • if a medical institution has provided meals to subscribers or dependents of health insurance in compliance with the personnel and facility standards under the Food Sanitation Act

6. 06Relation to precedent

   Follows earlier decisions Stated in the decision

   대법원 2019. 5. 30. 선고 2015두36485 판결(공2019하, 1310)

   Unofficial English translation

   Supreme Court Decision 2015Du36485 decided May 30, 2019 (Gong 2019 Ha, 1310)

   Decisions referred to

   [1] 대법원 2019. 5. 30. 선고 2015두36485 판결(공2019하, 1310)

7. 07Burden of proof

   Not addressed Not in the decision

8. 08Open question and revisit condition

   Where another individual administrative statute provides no sanction at all for the breach, or a sanction far below the benefit costs received, does recovery under Article 57(1) become necessary and to what degree?

   Any later Supreme Court decision weighing the necessity of recovery for a breach of a statute other than the Food Sanitation Act would test how far this standard travels. An amendment to Article 57(1) of the National Health Insurance Act or to Article 5(1) and Table 1, item 6(c) of the Rules on the Standards for Medical Benefits would require this entry to be read again.

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.

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