Disposition to Recover Medical Care Benefits

Medical care benefits refer to a system under which the National Health Insurance Service provides a fixed portion of the cost of medical treatment and care needed by the public due to illness, injury, childbirth, and similar circumstances.

They are provided as one form of insurance benefit under the National Health Insurance Act, and cover medical services in general, including examination and testing, the supply of medicines and treatment materials, and procedures and surgery.

After concluding a contract with the insurer, a medical care institution provides appropriate treatment to health insurance beneficiaries and, in return, claims benefit costs from the National Health Insurance Service.

Where a healthcare institution or a related party has received insurance benefits through deception or other improper means, the National Health Insurance Service may collect the full amount paid.

Such conduct falls under Article 57, Paragraph 1 of the National Health Insurance Act, and the collected amount may extend beyond a simple recovery to criminal punishment and administrative disposition.

For unlicensed practitioner hospitals and unlicensed practitioner pharmacies, that is, medical institutions or pharmacies unlawfully established and operated by borrowing another person's name, the National Health Insurance Service may also recover the medical care benefits that were paid.

For such unlicensed practitioner hospitals or pharmacies, the matter does not stop at recovery; the operator is directly assigned responsibility for paying the recovered amount, and in many cases strong measures such as criminal accusation and collection of equivalent value of property follow.

Where a medical care institution neglects to verify whether a person is eligible for insurance benefits, or issues a false medical certificate or confirmation document, such conduct is subject to a recovery disposition.

In such cases, joint liability may be imposed not only on the medical care institution but also on the medical practitioner and patient involved.

Where a person who received insurance benefits by deception or other improper means is a dependent, the National Health Insurance Service may also hold the subscriber jointly liable.

In other words, even if the insured person did not personally take part in the improper receipt, a joint obligation to pay the recovered amount may arise when a member of the same household received benefits improperly.

Where a medical care institution has improperly received medical care benefit costs, the National Health Insurance Service may recover such amounts from that institution.

In this case, the Service must return the improperly claimed amount to the insured or the dependent without delay, and where there is an amount payable, it may offset that amount against the insured's premiums and other charges.

If a party contests a disposition for recovery of medical care benefits, the party may file an administrative appeal with the Health Insurance Dispute Mediation Committee within 90 days from the date the disposition was received or within 180 days from the date the disposition was issued.

An administrative appeal is a procedure for requesting reexamination of an administrative agency's disposition, and it offers a relatively prompt and simple way to contest the legality of a disposition.

However, even if an administrative appeal has been filed, a separate administrative litigation may still be filed afterward.

Separately from administrative adjudication, a care institution may file an administrative litigation against a reclamation disposition.

In the course of the litigation, the burden of proving the impropriety of the reclamation disposition lies with the care institution, so the relevant evidence must be sufficiently prepared.

A revocation lawsuit must be filed within 90 days from the date the disposition became known, and it may no longer be filed once 1 year has passed from the date the disposition was made.

These two periods are not optional, so if either one passes, a revocation lawsuit can no longer be filed.

It is therefore very important to confirm the periods and file the lawsuit within the deadline.

① Denial of the Claim of Unjust Enrichment

The Service maintains that the medical care institution received insurance benefits through improper means, but the institution must establish that it actually claimed the benefits lawfully and in accordance with the prescribed standards.

② Proof of Absence of Intent or Negligence

Even if unjust enrichment exists, it must be shown that it did not arise from intent or negligence.

In other words, it must be actively explained that there was no fault in the medical treatment and billing process, and that the situation was unavoidable.

③ Denial or Reduction of the Loss Asserted by the Service

Even where the Service asserts that a loss has occurred, it is important to establish that there was in fact no loss, or that it was very minor.