Open Decision Ledger · Constitutional, administrative & state liability
Breach of another statute as improper means for benefit recovery
Supreme Court, July 9, 2020, 2020Du31668 (judgment)
Case name: 요양급여비용환수처분취소·업무정지처분취소
Official text on the National Law Information Center
Question
Where a medical institution provided medical care and medical aid benefits and received the benefit payments in breach of another individual administrative statute, does that amount to 'obtaining benefit payments by fraud or other improper means' under Article 57(1) of the former National Health Insurance Act and the suspension provisions of Article 98(1)(i) of the same Act and Article 28(1)(i) of the Medical Aid Act, and is a breach of the special medical equipment installation criteria other than the parts on registration and quality-management inspection such a ground?
Holding
It is not decided by the breach alone. Whether receiving benefit payments after breaching another individual administrative statute is 'obtaining benefit payments by fraud or other improper means' must be judged with the difference in legislative purpose and regulated subject matter between the health insurance and medical aid statutes and the other statute in mind, together with the content and purpose of the benefit criteria and with whether, and to what degree, recovery and suspension beyond the sanctions of the other statute are needed. The parts of the special medical equipment installation criteria other than those on registration and quality-management inspection are not grounds for recovery or suspension, even though they may ground a correction order under the Medical Care Act; so where A claimed computed tomography imaging fees and the like after a reading by a non-resident radiologist B and a passing quality-management judgement on registered devices, that could not be treated as fraud or other improper means.
Summary of the holding, verbatim
국민건강보험법·의료급여법과 다른 개별 행정법률의 입법 목적 및 규율대상의 차이를 염두에 두고 국민건강보험법령·의료급여법령상 급여기준의 내용과 취지 및 다른 개별 행정법률에 의한 제재수단 외에 국민건강보험법·의료급여법에 따른 부당이득징수 및 업무정지처분까지 하여야 할 필요성의 유무와 정도 등을 고려하여 판단하여야 한다.
Unofficial English translation
Keeping in mind the differences in the legislative purposes and objects of regulation between the National Health Insurance Act and the Medical Assistance Act and other individual administrative statutes, a determination must be made by taking into account, among others, the content and purport of the benefit standards under the National Health Insurance Act and subordinate statutes and the Medical Assistance Act and subordinate statutes, and whether and to what extent it is necessary to impose, in addition to the punitive measures under other individual administrative statutes, a disposition to collect unjust enrichment and a work suspension order under the National Health Insurance Act and the Medical Assistance Act.
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
국민건강보험법령·의료급여법령상 급여기준의 내용과 취지 및 다른 개별 행정법률에 의한 제재수단 외에 국민건강보험법·의료급여법에 따른 부당이득징수 및 업무정지처분까지 하여야 할 필요성의 유무와 정도 등을 고려하여 판단하여야 한다
Unofficial English translation
a determination must be made by taking into account, among others, the content and purport of the benefit standards under the National Health Insurance Act and subordinate statutes and the Medical Assistance Act and subordinate statutes, and whether and to what extent it is necessary to impose, in addition to the punitive measures under other individual administrative statutes, a disposition to collect unjust enrichment and a work suspension order under the National Health Insurance Act and the Medical Assistance Act
Factors
- 국민건강보험법·의료급여법과 다른 개별 행정법률의 입법 목적 및 규율대상의 차이를 염두에 두고
- 국민건강보험법령·의료급여법령상 급여기준의 내용과 취지
- 다른 개별 행정법률에 의한 제재수단 외에 국민건강보험법·의료급여법에 따른 부당이득징수 및 업무정지처분까지 하여야 할 필요성의 유무와 정도 등을 고려하여 판단하여야 한다
- 등록 및 품질관리검사에 관한 부분을 제외한 나머지 부분은 이를 위반한 경우
Unofficial English translation
• keeping in mind the differences in the legislative purposes and objects of regulation between the National Health Insurance Act and the Medical Assistance Act and other individual administrative statutes
• the content and purport of the benefit standards under the National Health Insurance Act and subordinate statutes and the Medical Assistance Act and subordinate statutes
• a determination must be made by taking into account whether and to what extent it is necessary to impose, in addition to the punitive measures under other individual administrative statutes, a disposition to collect unjust enrichment and a work suspension order under the National Health Insurance Act and the Medical Assistance Act
• as to the remaining parts other than those concerning registration and quality control inspections, in cases where they are violated
Relation to precedent
Follows earlier decisions Stated in the decision
대법원 2019. 11. 28. 선고 2017두59284 판결 참조
Unofficial English translation
see Supreme Court Decision 2017Du59284, decided November 28, 2019
Decisions referred to
[1] 대법원 2019. 5. 30. 선고 2015두36485 판결(공2019하, 1310), 대법원 2019. 11. 28. 선고 2017두59284 판결(공2020상, 189)
Burden of proof
Not addressed Not in the decision
Open question and revisit condition
What evidence shows that a non-resident radiologist actually performed the overall supervision of quality management and the evaluation of image quality without attending the medical institution?
The remand judgment of the Seoul High Court, once it finds whether the non-resident radiologist performed those tasks, will show how these criteria work in practice. Any amendment to Article 57(1) of the National Health Insurance Act, to the benefit criteria rules or to the special medical equipment rules, or a later Supreme Court decision on the same question, would require this entry to be read again.
Cross-family AI independent reading & axis check
7 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 7 of the 8 axes; the readings differed on axis 8 (open question and revisit condition).
Axis 8 (Open question and revisit condition): Primary “What evidence shows that a non-resident radiologist actually performed the overall supervision of quality management and the evaluation of image quality without attending the medical institution?” vs Independent “Under what circumstances would a failure to register special medical equipment or obtain the required quality inspection justify recovery or suspension?”
The primary reading points to evidence of whether the non-resident radiologist actually supervised quality management, while the independent reading points to when failing to register equipment would justify sanctions, so the open points differ.
국민건강보험법·의료급여법과 다른 개별 행정법률의 입법 목적 및 규율대상의 차이를 염두에 두고 국민건강보험법령·의료급여법령상 급여기준의 내용과 취지 및 다른 개별 행정법률에 의한 제재수단 외에 국민건강보험법·의료급여법에 따른 부당이득징수 및 업무정지처분까지 하여야 할 필요성의 유무와 정도 등을 고려하여 판단하여야 한다.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 9 January 2020 (2019Nu50139, 50146), took as its main ground the fact that A's non-resident radiologist did not attend the medical institution, and found that the specialist did not carry out the overall supervision of medical image quality management for the computed tomography devices or the evaluation of image quality. It then held that A's claims for computed tomography imaging fees and the like, paid as medical care and medical aid benefits, were obtained by fraud or other improper means within Article 57(1) and Article 98(1)(i) of the former National Health Insurance Act and Article 28(1)(i) of the Medical Aid Act.
Supreme Court standard: The Supreme Court held that this mistook the law on the benefit criteria under the National Health Insurance Act and the Medical Aid Act and on the targets of recovery and suspension. A non-resident radiologist need not attend the institution to perform quality management, image quality evaluation and clinical image reading, because those tasks can be done by checking the images taken, Article 34(1) of the Medical Care Act allows remote medicine, and the Ministry of Health and Welfare guideline requiring at least one weekly shift is an internal administrative rule with no external binding force. The whole judgment was reversed and remanded to the Seoul High Court.
Distinguishing conditions
- A benefit claim that breached the parts of the special medical equipment installation criteria dealing with registration or periodic quality-management inspection, which the Court kept outside its exclusion.
- A claim made without a passing quality-management judgement on the device or on a device that was not registered, since the Court's conclusion rested on a reading by a non-resident radiologist, a passing quality judgement and a registered device.
- A claim to which the National Health Insurance Act in force before the 3 February 2016 amendment (Act No. 13985), the benefit criteria rules before the 3 June 2016 amendment (Ministerial Decree No. 404) and the special medical equipment rules before the 10 January 2019 amendment (Ministerial Decree No. 613) applied, since the decision applied those earlier versions.
Record verification notes
Set the benefit claim against the three conditions the Court relied on: a reading by a non-resident radiologist, a passing quality-management judgement, and a registered device. Then check which version of the National Health Insurance Act, the Medical Aid Act, the benefit criteria rules and the special medical equipment rules applied on the date of the claim. Finally, see what sanctions the Medical Care Act itself provided, since the Court treated correction orders and the like as a separate matter.
From the official text
Points at issue
[1] 다른 개별 행정법률을 위반하여 요양급여·의료급여를 제공하고 급여비용을 수령한 것이 구 국민건강보험법 제57조 제1항에서 부당이득징수의 대상으로, 같은 법 제98조 제1항 제1호, 의료급여법 제28조 제1항 제1호에서 업무정지처분의 대상으로 각 정한 ‘속임수나 그 밖의 부당한 방법으로 급여비용을 받은 경우’에 해당하는지 판단하는 방법 [2] 의료법의 위임에 따른 구 특수의료장비의 설치 및 운영에 관한 규칙에서 정한 특수의료장비 설치인정기준(등록 및 품질관리검사에 관한 부분 제외)을 위반한 경우, 구 국민건강보험법 제57조 제1항에서 정한 부당이득징수처분 또는 같은 법 제98조 제1항 제1호, 의료급여법 제28조 제1항 제1호에서 정한 업무정지처분의 사유가 되는지 여부(소극) [3] 요양·의료기관을 운영하는 갑이 영상의학과 전문의 을 등이 실제 요양기관에 출근하지 않는 등 전산화단층 촬영장치 등의 의료영상 품질관리 업무의 총괄 및 감독, 영상화질 평가 등의 업무를 수행하지 않고 원격으로 판독 업무만 하였음에도 비전속 인력으로 신고하고 전산화단층 영상진단료 등에 관하여 요양급여·의료급여비용을 청구하여 지급받았다는 이유로 요양급여비용 환수처분 및 업무정지처분을 받은 사안에서, 갑의 요양급여·의료급여비용 청구가 구 국민건강보험법 제57조 제1항, 제98조 제1항 제1호, 의료급여법 제28조 제1항 제1호의 ‘속임수나 그 밖의 부당한 방법’으로 급여비용을 받은 경우에 해당한다고 볼 수 없는데도, 이와 달리 본 원심판단에 법리오해의 잘못이 있다고 한 사례
Unofficial English translation
[1] Whether providing medical care benefits and medical benefits in violation of other individual administrative statutes and receiving benefit expenses falls under 'cases of receiving benefit expenses by deception or other improper means' as defined in Article 57 (1) of the former National Health Insurance Act as the subject of a disposition to collect unjust enrichment, and in Article 98 (1) 1 of the same Act and Article 28 (1) 1 of the Medical Assistance Act as the subject of a work suspension order, and the method of determining such issue [2] Whether, in cases where the standards for the installation of special medical equipment (excluding the parts concerning registration and quality control inspections) prescribed in the former Regulation on the Installation and Operation of Special Medical Equipment, which is based on the delegation of the Medical Service Act, are violated, such violation constitutes a ground for a disposition to collect unjust enrichment prescribed in Article 57 (1) of the former National Health Insurance Act or a work suspension order prescribed in Article 98 (1) 1 of the same Act and Article 28 (1) 1 of the Medical Assistance Act (negative) [3] In a case where A, who operated a medical care and medical service institution, reported radiology specialists such as B as non-dedicated personnel although they did not actually report to the medical care institution and did not perform, among others, the work of overall control and supervision of medical imaging quality control for equipment such as computed tomography scanners and the work of image quality assessment, but only performed reading services remotely, and claimed and received health insurance benefits and medical benefits in respect of, among others, computed tomography imaging diagnostic fees, and therefore received a disposition to recover benefit expenses and a work suspension order, an instance where it was held that there was an error of misapprehension of legal principles in the determination of the court below, which decided otherwise even though A's claims for health insurance benefits and medical benefits cannot be regarded as cases of receiving benefit expenses 'by deception or other improper means' under Article 57 (1), Article 98 (1) 1 of the former National Health Insurance Act and Article 28 (1) 1 of the Medical Assistance Act
Summary of the holding
[1] 구 국민건강보험법(2016. 2. 3. 법률 제13985호로 개정되기 전의 것, 이하 같다)은 국민의 질병·부상에 대한 예방·진단·치료·재활과 출산·사망 및 건강증진에 대하여 보험급여를 실시함으로써 국민보건 향상과 사회보장 증진에 이바지함을 목적으로 제정된 법률이고, 의료급여법은 생활이 어려운 사람에게 의료급여를 함으로써 국민보건의 향상과 사회복지의 증진에 이바지함을 목적으로 제정된 법률로서 의료법 등 다른 개별 행정법률과는 입법 목적과 규율대상이 다르다. 따라서 다른 개별 행정법률을 위반하여 요양급여·의료급여를 제공하고 급여비용을 수령한 것이 구 국민건강보험법 제57조 제1항에서 부당이득징수의 대상으로, 구 국민건강보험법 제98조 제1항 제1호, 의료급여법 제28조 제1항 제1호에서 업무정지처분의 대상으로 각 정한 ‘속임수나 그 밖의 부당한 방법으로 급여비용을 받은 경우’에 해당하는지는 국민건강보험법·의료급여법과 다른 개별 행정법률의 입법 목적 및 규율대상의 차이를 염두에 두고 국민건강보험법령·의료급여법령상 급여기준의 내용과 취지 및 다른 개별 행정법률에 의한 제재수단 외에 국민건강보험법·의료급여법에 따른 부당이득징수 및 업무정지처분까지 하여야 할 필요성의 유무와 정도 등을 고려하여 판단하여야 한다. [2] 구 국민건강보험 요양급여의 기준에 관한 규칙(2016. 6. 3. 보건복지부령 제404호로 개정되기 전의 것, 이하 ‘건강보험 요양급여규칙’이라 한다)이 요양급여의 일반원칙으로 ‘요양기관은 가입자 등의 요양급여에 필요한 적정한 인력·시설 및 장비를 유지하여야 한다’고 규정한 취지는 요양기관으로 하여금 환자의 치료에 적합한 요양급여를 제공하게 하려는 것이고, 특수의료장비와 관련하여 ‘일정한 인력·시설을 갖추어 등록하고 정기적인 품질관리검사를 받을 것’을 요양급여의 기준으로 정한 것은 이를 구체화한 것이다. 그러므로 의료법의 위임에 따른 구 특수의료장비의 설치 및 운영에 관한 규칙(2019. 1. 10. 보건복지부령 제613호로 개정되기 전의 것)에 정한 특수의료장비 설치인정기준 가운데 등록 및 품질관리검사에 관한 부분을 제외한 나머지 부분은 이를 위반한 경우 의료법에 따라 시정명령 등의 제재 사유가 됨은 별론으로 하더라도 구 국민건강보험법(2016. 2. 3. 법률 제13985호로 개정되기 전의 것, 이하 같다) 제57조 제1항에서 정한 부당이득징수처분 또는 구 국민건강보험법 제98조 제1항 제1호, 의료급여법 제28조 제1항 제1호에서 정한 업무정지처분의 사유가 된다고 볼 수 없다. [3] 요양·의료기관을 운영하는 갑이 영상의학과 전문의 을 등이 실제 요양기관에 출근하지 않는 등 전산화단층 촬영장치 등의 의료영상 품질관리 업무의 총괄 및 감독, 영상화질 평가 등의 업무를 수행하지 않고 원격으로 판독 업무만 하였음에도 비전속 인력으로 신고하고 전산화단층 영상진단료 등에 관하여 요양급여·의료급여비용을 청구하여 지급받았다는 이유로 요양급여비용 환수처분 및 업무정지처분을 받은 사안에서, 갑이 비전속 영상의학과 전문의의 영상판독을 거쳐 품질관리 적합판정을 받고 등록된 전산화단층 촬영장치 등을 활용한 전산화단층 영상진단료 등을 요양급여비용 또는 의료급여비용으로 청구하였다면 이를 구 국민건강보험법(2016. 2. 3. 법률 제13985호로 개정되기 전의 것) 제57조 제1항, 제98조 제1항 제1호, 의료급여법 제28조 제1항 제1호의 ‘속임수나 그 밖의 부당한 방법’으로 급여비용을 받은 경우에 해당한다고 볼 수 없는데도, 이와 달리 본 원심판단에 법리오해의 잘못이 있다고 한 사례.
Order
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.
Provisions referred to
[1] 구 국민건강보험법(2016. 2. 3. 법률 제13985호로 개정되기 전의 것) 제57조 제1항, 제98조 제1항 제1호, 의료급여법 제28조 제1항 제1호 [2] 구 국민건강보험법(2016. 2. 3. 법률 제13985호로 개정되기 전의 것) 제57조 제1항, 제98조 제1항 제1호, 의료급여법 제7조 제2항, 제28조 제1항 제1호, 구 의료급여법 시행규칙(2020. 6. 29. 보건복지부령 제737호로 개정되기 전의 것) 제6조 제1항, 구 국민건강보험 요양급여의 기준에 관한 규칙(2016. 6. 3. 보건복지부령 제404호로 개정되기 전의 것) 제5조 제1항 [별표 1] 제1호 (라)목, 제8호 (라)목, 의료법 제1조, 제34조 제1항, 제38조 제1항, 제2항, 제3항, 제63조 제1항, 제64조 제1항 제6호, 제67조 제1항, 제88조 제1호, 구 특수의료장비의 설치 및 운영에 관한 규칙(2019. 1. 10. 보건복지부령 제613호로 개정되기 전의 것) 제3조 제1항 [별표 1], 제2항 제1호 [3] 구 국민건강보험법(2016. 2. 3. 법률 제13985호로 개정되기 전의 것) 제57조 제1항, 제98조 제1항 제1호, 의료급여법 제28조 제1항 제1호
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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