현행 실손의료보험 제도의 문제점 분석과 표준약관상 보장 및 면책조항에 대한 소비자의 이해가능성 제고를 위한 연구 - 약관구성 형식과 내용의 변경을 통하여 -

박세민 한국경영법률학회 2013 經營法律 Vol.23 No.3

In the situation that only 63% of amount for medical expenses is borne by the national health insurance. public insurance, almost half the number of people have currently taken up health insurance policy for actual loss and damage, a private insurance product and it is expected that, even in the future, the demand for such product will continuously increase. However, current system of health insurance for actual loss and damage shows a lot of problems: from the perspective of consumers, wide range of increase of insurance premium dissatisfies; and, even from the perspective of insurance companies, their loss ratio has consistently increased as the amount of insurance to be paid has rapidly increased. It can be said that the important reasons for the problems of current system of health insurance for actual loss and damage are: excessive use of medical institutions by consumers insured by health insurance for actual loss and damage; excessive medical treatment of medical institutions to such consumers; and non-payment items of medical treatment and non-existence of control over the cost for such items under the National Health Insurance Act. In addition, in light of its easiness, conciseness and clarity, current standardized contract of medical insurance for actual loss and damage has lots of problems. From consumers' point of view, the pages of such contract are too numerous. The reason is that, in the standardized contract, the insured items are classified into injuries and diseases, respectively, and thereafter, medical costs for both inpatient and outpatient is respectively divided for each items. After then, all the sub-items of inpatient and outpatient to be covered and not covered by insurance are respectively set forth. In order to decrease the quantity of the standardized contract, the insured items to be classified must be changed into inpatient and outpatient and then, it is necessary to set forth the contents of insurance coverage and grounds for exemption from responsibility which can be commonly applicable. After then, the matters to be individually applied should be separated and prescribed in the items subject to such application. By doing this way, considerable quantity of the standardized contract will diminish. The languages of current standardized contract are not so clear that there is possibility of dispute regarding the construction of contract and, thus, in order to enhance consumers understanding, it is necessary to move several provisions of the contract into other parts of the contract. Given its importance and popularity, the contents of standardized contract of health insurance for actual loss and damage should be continuously amended from now on and the direction of such amendment must be for enhancing its easiness, conciseness and clarity.

醫療賠償責任保險에 관한 硏究

이재형 공주문화대학 1999 공주문화대학·논문집 Vol.26 No.-

The aim of this paper is to review the Medical malpractice insurance system. To make a long story short, that is revitalization of Medical professional liability insurance system. The insurance should be a compulsory insurance. Of course, the insurer could be an insurance company or physicians' mutual benefit association. We could get prompt and reasonable solutions of medical malpractice disputes with that system. Medical professional liability insurance system could bring quicker settlements than traditional court proceedings and reduce litigation-costs after all. For this reason, this thesis consists of five chapters. Chapter 1 is devoted to the introduction, purpose and scope of the study, in this chapter, this writer indicates the importance of prompt and reasonable settlement of medical malpractice disputes. Chapter 2 deals with significance relating to the Medical malpractice insurance system This chapter is consisted of three parts those are liability insurance of professionals and liability insurance of medical malpractice and compensation of indirect casualties Chapter 3 deals with direction of legislation of Medical malpractice insurance system. At first, in this chapter, I considered the possibility of inducement of the compulsory medical malpractice insurance and the contraction with the insurer of medical malpractice in a party. Second, I insists on the abandonment of rights about indemnity of the Medical insurers. Chapter 4 deals with the contents of those duties of the insurer and the insured the comparison of the policy of occurrence basis and the policy of claims-made basis the scope of guarantee, the exemption from the responsibility of the insurer. Now-a-days, a few insurers reopen the medical malpractice insurance but they have anxiety of excessive losses. So, the discussion is made to find out how to develope the medical malpractice insurance in Korea. Finally, Chapter 5 concludes this thesis by suggesting the development of the institutional devices for the guarantee of our peoples' Rights to health and Rights to Health Care.

지역의료보험 실시전후 도시 일부주민의 의료이용양상 비교 - 소득 계층별 의료필요충족도와 주민 만족도를 중심으로 -

김석범,강복수,Kim, Seok-Beom,Kang, Pock-Soo 대한예방의학회 1994 예방의학회지 Vol.27 No.1

대구직할시 남구 1 개동 주민을 대상으로 도시 지역의료보험 실시 전후(이하 실시 전후)의 의료 이용양상을 파악하기 위하여 실시 6개월 전인 1989년 1월에 1차조사를 하였고, 실시 1년 6개월 후인 1991년 1월에 2차조사를 하였다. 1차조사의 대상자는 1,230가구 4,939명이 었으나, 2차추적조사가 가능했던 인구는 519가구 2,277명 (추적률:46.1%)이었다. 2차조사까지 추적이 가능했던 2,277명 중 1차 조사시 보험에 가입되지 않았던 240가구 1,033명을 코호트 I군(이하 I군)으로 하였고, 1차조사시 보험에 가입되었던 279가구 1,244명을 코흐트 II군(이하 II군)으로 구분하여 조사자료를 분석하였다. 인구 1,000명당 급성이환으로 인한 의사방문율의 변화는 실시 후에 I군에서 16.5 증가한 반면, II에서는 2.4만 증가하였으며, 만성이환에서도 I군이 13.5 증가하였으나 II군은 7.2만 증가하였다. 이환 및 활동제한 의료필요 충족률도 I군에서 실시 후 뚜렷히 증가하였다. 월가구소득별 급성이환에 의한 의료필요충족률은 I군에서 40만원미만군이 1.6으로 $40{\sim}99$만원군의 4.0과 100만원이상군의 49.3에 비해 월등히 낮았다. 이러한 소견은 나머지 조사대상군과 만성이환에서도 동일하였다. 급성과 만성이환자의 병원이용 이유는 유용성, 의원의 경우는 지리적 접근성이 실시전후모두에서 가장 많았고 약국이용 이유 중 실시 전에는 접근성과 의료비지불성이 중요하였으나, 실시 후에는 의료비지불성의 중요성은 상대적으로 감소하였다. 최근 15일간 의사방문여부를 종속변수로한 multiple logistic regression analysis에서 급성이환(+), 만성이환(+) 그리고 월가구소득(+)이 실시전후 모두에서 유의한 변수였다. 실시 후 부과된 보험료에 대한 불만족률이 두군 모두 지역의료보험 가입자에서 각각 81.0%와 74.1%로 타 의료보험가입자에 비해 월등히 높았다. 실시 후 병원과 의원의 의료비와 서어비스에 불만족스럽다고 응답한 사람이 I군에 비해 II군에서 더 많았다. 이상의 소견으로 의료보험이 실시됨으로 미충족의료수요를 감소시키는 효과를 가져왔으나 실시 후에도 저소득층의 의료이용률이 고소득층에 비해 여전히 낮아 의료보험실시로 경제적 장애가 감소하였음에도 불구하고 본인부담금 등으로 인한 경제적 장애와 의료기관을 방문하는데 소요되는 시간, 대기시간 등 의료이용을 저해하는 요인이 남아있어 의료이용의 형평이 사회계층들간에 완전히 이루어지지는 않았다. 특히 만성이환의 경우, 불균형이 심하였다. 또한, 부과된보험료에 대한 불만족도가 높아 현행 보험료선정기준의 재평가 및 공정성을 향상시킬 필요성이 제기되었다. The effects of regional medical insurance on utilization of medical care in urban population was examined in this study. The data was collected in a 2-year follow-up household survey conducted at Taegu city before and after implementation of the regional medical insurance. The study population was divided into 2 groups. Cohort I was the uninsured in 1989 and cohort II was the insured in 1989. After the coverage of medical insurance, physician visit rate per 1,000 population, use-disability ratio and use-restricted activity ratio in cohort I were increased compared to cohort II in both of acute and chronically ill people. The use-disability ratio and use-restricted activity ratio of the insured poor were lower than those of the insured nonpoor in both of cohort I and cohort II. The major reasons for pharmacy use were accessibility and affordability before the coverage of medical insurance in cohort I, however, after the coverage of medical insurance, the important reason was accessibility rather than affordability. In logistic regression analysis of physician visit, the significant independent variables were acute illness episode (+), chronic illness episode (+) and income (+) in both of cohort I and cohort II. In cohort I, after the coverage of medical insurance, more people replied that the medical cost of hospital and clinic was reasonable. The people who covered by the regional medical insurance were more dissatisfied with the imposed premium than those who covered by other types of medical insurance in both of cohort I and cohort II. More people in cohort II than cohort I were dissatisfied with the services from hospitals and clinics after implementation of the regional medical insurance. In conclusion. after the coverage of medical insurance, the gap between the poor and the nonpoor still exists in terms of medical care utilization.

실손의료보험과 비급여 의료비 심사제도 도입의 필요성- 금융분쟁조정위원회 2016. 5. 24. 결정 제2016-12호에 대한 평가를 겸하여 -

명순구 한국경영법률학회 2016 經營法律 Vol.27 No.1

이 논문은 금융분쟁조정위원회의 조정 결정(2016. 5. 24. 결정 제2016- 12호)에 대한 평가를 통하여 실손의료보험과 비급여 의료비 심사제도 도입의 필요성을 밝히기 위한 것이다. 연구대상결정은 실손의료보험 계약자와 보험사 간에 실손의료비 지급과 관련하여 금융감독원 금융분쟁조정위원회에서 최초로 다루어진 사안이라는 점에서 의미가 크다. 국민건강보험의 보장률이 저조한 상황에서 의료비 부담을 덜기 위해 60% 이상의 국민이 실손의료보험에 가입하고 있으나 손해율 급등으로 인한 보험료 인상 앞에서 그 지속가능성이 위협받고 있다. 이는 매우 중대한 문제이다. 의료비는 단순한 비용에 그치는 것이 아니라 헌법적 개념인 의료복지 차원의 이슈이기 때문이다. 실손의료보험의 이슈에 관해서는 관련 당사자에 따라 상당한 시각차가 존재한다. 이러한 시각차에도 불구하고 실손의료보험의 지속적 유지를 위해서는 무언가 제도 개선이 필요하다는 점에 대해서는 이견이 없다. 연구대상결정에서 문제된 도수치료란 손으로 마사지하여 근육 긴장을 풀어주고 관절을 교정하는 물리치료법을 말한다. 이 시술은 법정비급여 항목에 속한다. 실손의료보험은 국민건강보험이 보장하지 않는 법정본인부담금과 비급여의료비 등을 보장한다. 「국민건강보험법」 및 기타 법령에 가격과 수량 등이 통제되는 급여 의료비와 달리 비급여 의료비는 완전한 자율 영역에 맡겨져 있다. 이 영역은 긍정적으로는 최상의 의료서비스를 추구할 수 있는 토대가 되지만, 부정적으로는 과잉진료와 같은 자원의 비효율적 배분 또는 도덕적 해이의 원인이 될 수 있다. 이와 같은 부정적 현상의 전형으로 지적되어 온 것이 도수치료이다. 현재 비급여 의료비를 관리하기 위한 제도가 운영되고 있다. 비급여 진료비용 고지 제도, 현지조사 제도, 진료비 확인청구 제도 등이 그것이다. 그런데 이들 제도는 비급여 의료비의 효율적 관리라는 목적을 달성하기에 부족한 실정이다. 실손의료보험에 과한 제도 개선과 관련하여 의료기관으로 하여금 보험사에 보험금을 직접 청구하는 방식으로 전환해야 한다는 제안, 비급여 의료비를 통제하기 위하여 전문심사기관으로 하여금 의료비심사를 담당하도록 해야 한다는 제안 등 관련 논의가 축적되어 있다. 특히 전문심사기관에 의료비심사를 위탁하자는 제안은 국민권익위원회, 금융위원회 및 법률개정안으로도 제출된 바가 있다. 이제는 비급여 의료비 심사제도를 마련해야 하는가 여부에 대한 고민을 넘어 그 방법을 고민해야 할 시점이라고 본다. 그리고 이를 위해서는 비급여 분류 및 항목의 표준화 등 관리체계의 정비를 위한 선결작업들이 보다 적극적으로 추진되어야 한다. 의료서비스의 특성상 가격은 시장기제만으로 적정하게 형성되기는 어렵다. 따라서 복지국가의 관점에서 의료서비스 가격의 형성과 지급에 국가가 다양한 방식으로 개입하게 된다. 연구대상결정은 금융분쟁조정위원회의 조정 결정으로서 종국적인 분쟁해결책은 아니지만, 국민에 대한 의료보장이라는 큰 틀 안에서 실손의료보험 제도의 역할과 미래상을 정립하는 데에 문제인식을 공유하는 하나의 계기이다. 연구대상결정이 헌법적 가치를 내포하는 의료보장제도의 중요성에 공감하고 비급여 의료비에 대한 심사제도의 도입 문제를 적극적으로 논의하는 계기가 되기를 기대한다. The present paper was written in order to emphasize the necessity of introducing an evaluation system of fee-for-service health insurance and uninsured medical expenses by assessing the May 24, 2016 decision #2016-12 (hereinafter, subject decision) of the Financial Disputes Mediation Committee (hereinafter FDMC). The subject decision is essential in that it was the first time the FDMC of the Financial Supervisory Service took up the matter of fee-for-service medical fees between parties to a contract on fee-for-service health insurance. Given the low rate of coverage by the National Health Insurance, more than 60% of the general public subscribe to fee-for-service health insurance, in order to lessen the burden of medical expenses. However in the face of an increase in insurance premium caused by the surge in loss ratio, the sustainability of the system is under question. This is a critical problem. Medical expenses are more than just costs. They are related to medical welfare which is a constitutional issue. The per- spectives on the issue of fee-for-service health insurance vary signifi- cantly. Despite such conflicting views, everyone agrees that only by improving the health insurance system can the fee-for-service health insurance remain sustainable. In the subject decision the manual therapy under question is a method of physical treatment that is employed by massaging with the hands in order to relax muscles and correct joints. Such treatment is not covered by health insurance. Fee-for-service health insurance covers deductibles not covered by National Health Insurance and uninsured medical expenses. Unlike covered medical expenses, the price and amount of which are regulated by the National Health Insurance Act and other legislation, uninsured medical expenses are wholly left outside any realm of regulation. On the positive side, this may serve as the basis for providing the highest level of medical services. However on the negative side it may result in excessive treatment and moral hazard. Manual therapy is seen as a telling example of the latter. Currently there are systems in place that regulate uninsured medical expenses: system of notification of uninsured medical expenses; system of field investigation; system of confirming expenses. However these systems leave a lot to be desired in achieving an efficient management of uninsured medical expenses. Many proposals are being made with regard to the improvement of the fee-for-service health insurance. Some suggest that medical facilities should address the insurer directly, whereas others argue that specialized evaluation institutions should assess medical expenses so as to regulate uninsured medical expenses. The latter has been proposed by the Anti- corruption & Civil Rights Commission of Korea, Financial Supervisory Service and a draft bill. Now it is not merely a question of whether a system for evaluating uninsured medical expenses should be adopted but a question of how it should be done. In order to do this the classification of uninsured medical expenses and standardization of items should be addressed first. Given the nature of medical services, its price cannot be left to be determined solely by the market. From a welfare state perspective there are various ways in which a state can intervene in determining the price of medical services. Although the subject decision as a method of dispute settlement by the FDMC is not final, it can serve as a stimulus in raising awareness of the role and future vision of fee-for- service health insurance. Hopefully this paper can contribute to the discussion on the importance of health insurance that reflects consitutional values as well as the introduction of the system of evaluation of uninsured medical expenses.

Legal System for Medical Liability Insurance Relevant to AI Doctor in China

나찬,류사문,왕의흠 원광대학교 법학연구소 2022 의생명과학과 법 Vol.27 No.-

Since artificial intelligence was proposed in the last century, the technological advancement has been promoting the development of AI doctor, which has already entered the medical life in China. As AI doctors are based on elements such as big data and evolutionary algorithms, they have new knowledge learning capabilities and massive information processing capabilities that far exceed those of human doctors, and can provide patients with more efficient and high-quality medical services. Its accuracy in diagnosing and treating diseases is also much higher than that of human doctors. Thus, AI doctors have bright future in the entire life cycle of medical activities such as medical consultation, intelligent diagnosis, intelligent treatment, and health management. At the same time, the continuous medical damages of AI doctors used in the market indicate that it has a huge potential risk, for the existence of technical black boxes may cause irreversible damage to the personal health of patients. As a financial way to protect victims and diversify social risks, medical liability insurance plays a vital role in promoting the development of new technologies and solving related medical damage. However, our nation's medical liability insurance system is facing difficulties and is currently unable to perform its due function. On the one hand, insufficient compulsory medical liability insurance has led to insufficient coverage, the coverage of insurance is too narrow, and the existing problems of imperfect supporting systems have not yet been resolved, and medical liability insurance has its own development difficulties; More importantly, the participation of AI doctors has a huge impact on the doctor's fault identification and traditional fault liability, and the relationship between the relevant insurance systems is also quite chaotic. Artificial intelligence poses a challenge to the current medical liability insurance legal system, and it is urgent to improve and reform medical liability insurance. In this regard, in the future medical liability insurance, these existing and new problems should be fully considered. The key points are the identification of fault, the introduction of no-fault compensation, and the linking to related insurance systems. This is the main direction for the improvement of the legal system in the future. Specifically, in the future, the improvement of our country's medical liability insurance legal system should conform to the technological development of AI doctors, improve the traditional fault identification, introduce no-fault compensation to reform the traditional principle of single fault, and clarify the relationship between various insurances to relieve the parties.

老人長期療養報障制度에 대한 比較法的 硏究

장두순 한국비교노동법학회 2009 노동법논총 Vol.16 No.-

In Korea, the number of the elderly has rapidly increased. In 2007, the percentage of the population aged 65 years or older has reached 9.9%. In this society of the old, the problem of the long-term care of the elderly is not only a problem for the individual family but for the society as a whole. In Germany and Japan, the long-term care insurance system has emerged as an answer to the problem of the rising medical costs of the elderly. Now, the Republic of Korea is trying to resolve the problem of the long-term care of the elderly by adopting a similar long-term care insurance scheme. The resulting recommendations for an improvement plan of the long-term care insurance of the elderly include: (1) Areas of a service supplementation. Firstly, it is difficult to enlarge caretaking facilities on short notice. Even if the numbers of the facilities are sufficient, new problems of the management of these facilities arise. To resolve these problems, it is necessary to increase the extent of the homecare service. Here, in order to prevent the waste of the insurance premiums, services not covered by the regulations should be paid by the family. Moreover, a national supplement policy for the elderly is needed, that supports the self-care community of the elderly. As in the case of Sweden, allowing specialized hospitals for the elderly to provide home-visit nursing care can be a solution for the shortage of nursing hospitals. Secondly, caretaking professional teaching programs must be improved. In the case of Germany and Japan, the training periods forthe caretakers are set at two to three years for a systematic education and the national licensing exam. In Korea, there are no definite provisions in the long-term care insurance law for the enforcement of regulations about the education of the caretakers. The government should make clear regulations concerning education periods and, especially, the period of the practical education. The organization of the exercise program should be licensed to caretaking hospital as well as to general hospitals. Thirdly, the "Family Long-term Care System" must be expanded. This system is only permitted in areas of the countryside that lack professional long-term caregivers and in the case of natural disasters. It is more economical to expand the Family Long-term Care System to lessen the expenses for the caretaker facility enlargement. Fourthly, the numbers of the management work force have to be raised. The supervisory system must be regulated in a way that clearly outlines the limitsof long-term care service. This means that a qualified management work force training system is needed. Fifthly, a volunteer system must be included in the long-term care service system. To foster a climate of volunteering services, a revision of the education law is needed so that related education programs can be newly introduced. (2) The objectives of the long-term care giving services should be enlarged. Firstly, the law of the objectives of the payment must be revised. Here, as beneficiaries, the disabled should be included. The disabled should be recipients of the long-term care giving service regardless of age. The financial resources for them should comefrom welfare budgets for the disabled. Secondly, the final entitlement evaluation should be done only by doctors; if the persons concerned are dissatisfied, a secondary evaluation should be made. The contents of the evaluation should be easy to be understood by common people. Thirdly, the concept of dementia must be defined. The improvement of the dementia symptoms is difficult judge. The law has no clear definitions of dementia, which will invite legal disputes. Fourthly, the scope of recipients of the elderly long-term care insuranceexcludes patients with severe symptoms. This will lead to objections by thepatients. Objective standards about recipients and payment regulation should be revealed (3) We should recheck the medical treatment service in the long-term insurance system. Firstly, we should recheck the effectiveness of the wireless paging project. We should establish a "mutual self-help system of the elderly". Especially, volunteer networking systems should be encouraged. Secondly, we should establish a voucher system and a preventive welfare system for the elderly. Thirdly, there are no provisions terminally ill patients. Care services for them must be included. Fourthly, we should prepare for payment systems and their control. Without proper control systems, there will be moral hazards with the imbursement of family medical treatment costs. (4) We should establish an objective entitlement level evaluation and control system. The decision process should be opened to the public by internet and public notice board. Firstly, level evaluations should be given after careful consideration in two stages. The supervision of service institutes and personal should be strengthened. Secondly, we should make multiple investigations for the preparation of reports of the medical situation. With recipients who receive high amounts of financial support, the medical certificates must be submitted to the authorities. Through this certification process, costs for those patients can be saved. (5) We should prepare sound financial planning for the long-term care of the elderly. Firstly, medical expenses for the aged and nursing expenses are increased like in Sweden. We should investigate the introduction ofa publicmedical public management, which unifies the welfare and medical services. Secondly, staying in long-term care hospitals is quite expensive. A self-supporter community, like in the United States, is recommendable to residents who live in the countryside and outskirts of the cities in Korea. In an industrialized country, staying at home is more common than staying at s hospital. Thirdly, we should introduce an insurance system for parents. In Korea, most of the old generation is not prepared for their declining years. Therefore, we should introduce an insurance system for parents financed by their sons and daughters. Fourthly, subdividing the levels of medical treatment is problematic. Presently, there are three levels of medical treatment. However, the gaps between each level are too large. Therefore, the financial situation of the insurance may change for the worse because of excessive payments. By subdividing the medical treatment levels, establishing preventive medical treatment systems may reduce medical payments. Fifthly, elderlyperson who applied for the long-termcare service should pay for their meals and room costs. This may prevent excessive payments by the long-termmedical treatment insurance. Only the poor people who receive livelihood expenses by the government need not pay for their meals in hospitals. Sixthly, for the financial stability, the retiring age should be extended. For this purpose, wage peak systems and job training systems for the elderly must be introduced. Seventhly, preventive measures against diseases of the elderly should be established. If one becomes sick, he will be a burden to his family and himself and medical costs will be increased. Therefore, we should establish a system of health support for the aged and support the aged who exercise through subsidies by the government. Eighthly, the present government tries to privatize the national health insurance. However, the privatization should be considered as a supplement for problematic fields of the public insurance sector. Private insurance should be made available along with national health insurance according to one's choice. In conclusion, the introduction of the long-time medical treatment insurance for the elderly is inevitable because of our progressing to an aging society. However, the financial maintenance of this system remains the core problem. For the prevention of moral hazards in the implementation of this system, we should establish various control systems.

자동차보험 진료수가제도의 적정화 방안에 관한 연구

조규성(Cho Gyu-Seong) 부산대학교 법학연구소 2010 법학연구 Vol.51 No.2

자동차보험 진료수가의 의미에 대해서는 자동차손해배상보장법 제2조 제7호에서 명확하게 정의하고 있지만 자동차보험 보상실무에서는 이의 적용을 둘러싸고 오랫동안 보험업계와 의료업계간에 첨예한 대립이 생기고 있다. 특히 국토해양부장관의 ‘고시’로 시행되고 있는 ‘자동차보험 진료수가기준’을 적용함에 있어서 동 고시의 법적성격에 대해 의료기관과 법원의 입장은 법규명령으로서의 대세적 효력 인정을 부정하고 있는 반면에, 보험회사는 대세적 효력을 인정하여 자동차사고 피해자들에게 ‘자보수가기준’의 적용을 강제하는 획일적인 업무처리로 인해 많은 불편과 피해를 주고 있는 실정이다. 그 밖에도 자동차보험 진료수가와 관련한 여러 문제들로 인해 보험소비자는 자동차사고를 당했지만 적절한 치료를 받지 못하는 문제가 발생하기도 한다. 따라서 본 논문에서는 현행 자동차보험 진료수가가 안고 있는 근본적인 문제점들 특히 건강보험수가와의 가산율 차이와 진료비 심사체계의 비효율성에 대한 문제점 분석과 이에 대한 개선방안으로 자동차보험 진료수가의 건강보험수가와 일원화 방안과 진료수가체계를 행위별 수가제가 아닌 포괄수가제의 도입을 통한 분쟁해결방안의 제안 등을 통해 필자 나름의 해결책을 제시해 보았다. 나아가 현행 자동차보험 보상실무에서 ‘자보수가’의 적용과 관련된 기타 문제점들 예컨대 선택진료비의 인정문제와 기왕증 진료비에 대한 효율적 처리방안, 향후진료비의 자보수가 적용문제와 과도한 입원환자에 대한 보험회사의 진료비 임의삭감문제의 해결방안과 자동차보험진료수가 분쟁심의회와 관련된 문제점과 개선방안 등에 대해서도 살펴보았다. 결론적으로 본 논문에서 제안한 사항은 논의의 결론이라기보다 사회적 논의의 새로운 출발을 위한 제안이라고 봐야 할 것이다. 향후 더 많은 연구와 노력을 통해 자동차보험 진료수가제도가 적정화되고, 나아가 보험회사와 의료기관, 피해자 모두가 만족할 수 있는 제도가 될 수 있도록 후속 조치들이 뒤따라야 될 것으로 본다. Automobile insurance in Korea is kind of liability insurance which has a purpose of compensating the demage as the insured becomes legally obligated to pay as demage of automobile accident of injury. However comparing the Automobile Insurance Medical Fee automobile accident of injury. However comparing the Automobile Insurance Medical Fee with the Medical Fee of Public Health Insurance by focusing on the level of medical fee, the Automobile Insurance Medical Fee is higher than the Medical Fee of Public Health Insurance. On the ground of that reason, the resolution of the victim compensation of patients need to be estimate the percentage of apportionment of medical fee. In case of regular insurance accident, claim of insurance money is given to the insurer. There are many claims in payment of medical fee which occurred complexly by breach of driver's duty and patient's predisposition. The objective of this study is to meet the foregoing necessity, that Automobile Insurance Medical Fee need to be squared with the Medical Fee of Public Health Insurance, and need to be squared with medical fee examination system both medical fees for efficiency. Also medical service charges in automobile insurance, along with Industrial Disaster Compensation Insurance should be in line with Public Health Insurance and selective consultation system should be abolished.

임의비급여진료행위병원에대한민사적쟁점검토 - 보험자의 채권자대위권 행사 가부를 중심으로 -

임웅찬(Lim, Ung Chan),이상강(Lee, Sang Kang),김형진(Kim, Hyung Jin) (사)한국보험법학회 2019 보험법연구 Vol.13 No.2

국가의 국민에 대한 보건의무를 규정한 헌법 제36조 제3항의 규정과 국민건강 보험법을 근거로 설립된 국민건강보험공단은 한정된 재원으로 국민의 보건향상에 기여하고 있다. 그러나 현실적으로 모든 의료서비스에 소요되는 비용을 공단에서 부담할 수 없는바, 국민건강보험법은 요양급여에 대하여는 공단과 환자가 각 부담하도록 하되, 업무 및 일상에 지장이 없는 의료행위에 대하여는 비급여로 구별하여 이 부분에 한하여 환자와 의료기관 사이의 합의에 따라 의료행위를 할 수 있는 사적자치(私的自治) 영역으로 두고 그 진료비에 대하여는 환자에게 전액 부담하도록 하고 있다. 위와 같이 공단이 모든 의료비를 보장하는 것이 아니라 진료비 중 일부만 보장하고, 나머지 진료비는 환자들이 부담해야 하기 때문에 환자들은 개인적으로 보험사와 진료비를 보장하는 보험계약을 체결하여 자신의 부담을 민영 보험사에게 맡기고 있다. 현재 우리나라 국민의 3분의 2 가량이 가입하고 있는 실손보험은 국민보건 향상이라는 역할에 비추어 볼 때 강제보험은 아니지만 매우 중요한 보험임에는 틀림이 없다. 한편, 정부에서는 건강보험의 보장범위를 확대하는 정책을 실시함으로 건강보험에서 비급 여가 줄어들어들게 되자 의료기관은 실손보험 가입자를 상대로 과잉 과다진료를 하고 있다.이렇게 과잉 과다진료, 임의비급여 진료를 제공함으로 수익을 창출하고자 하는 의료계의 이해관계와 이러한 과잉 과다진료 및 임의비급여 진료를 적극적으로 이용하고자 하는 환자들의 이해관계가 맞아 떨어져 실손보험의 지급률이 매우 가파르게 오르는 등 심각한 상황에 직면 하고 있다. 일부 의료기관과 환자 등 사회 구성원간 조금씩 자행되는 도덕적 해이가 결국 보험자 뿐 아니라 결국은 다른 선량한 보험가입자와 전체 국민에게 큰 부담으로 돌아가게 되는 것이다. 이러한 문제점을 바탕으로 본고에서는 실손의료보험자가 환자인 피보험자에게 보험금으로 지급한 임의비급여 진료비를 의료기관으로부터 직접 환수하는 방안에 대한 법적 구성을 어떻게 할 것인지가 문제된다. 먼저, 보험자가 직접 의료기관을 상대로 불법행위를 원인으로 손해배상청구를 할 수 있는지 여부를 살펴본다. 대상판결의 상고심에서는 의료기관의 행위와 보험자의 손해 사이에 인과관계가 없다는 이유로 불법행위책임을 부정하였다. 그러나 실손보험의 가입자 수가 다수 이고, 의료기관에서 실손보험 청구를 위해 필요한 각종 서류를 발급해 주는 등 진료를 받은 환자가 실손의료비를 청구하리라는 사정을 충분히 인지할 수 있는 점 등에 비춰볼 때 인과 관계를 부정할 수 없을 것이다. 이러한 점에서 대상판결의 상고심 결론에는 동의하기 어렵다. 다음으로, 채권자대위권을 근거로 보험자가 직접 환자인 피보험자의 권리를 대위하여 행사하는 방안을 적극 검토해 볼 필요가 있다. 이에 대하여 채권자대위권의 태동적 한계를 언급하면서 강제집행을 위한 보조수단으로서 채무자의 책임재산으로 충분히 변제 자력을 없는 경우에만 활용할 수 있도록 제한적으로 해석하는 입장이 있다. 그러나 우리 대법원 판결 및일본 최고재판소 판결은 채권자대위권의 독자적인 기능을 인정하여 일정한 경우에는 채무자의 변제자력, 책임재산 유무와 관련 없이 인정할 수 있다고 판단하고 있다. 이러한 판단은 채권자의 채권이 특정물 채권인지, 금전채권인지 여부에 따라 달라질 것은 아니라고 본다. 본고의 대상판결에서도 보험자에서 환자인 피보험자를 거쳐 의료기관에 지급된 금전이 결국 보험자로 다시 반환되어야 하는 상황이라면 이해관계가 없거나 때로는 의료기관의 임의비급여 행위에 가담하여 보험자에게 손해를 가한 피보험자(환자)를 거치지 않고 채권자인 보험자 에게 바로 반환할 수 있는지가 쟁점이 되었다. 결론적으로 대상판결은 보험자에게 민법에 규정된 채권자대위권 행사를 인정함으로써 향후 유사사안에 대해 방향성을 제시한 의미있는 판결이라 할 것이다. The National Health Insurance Corporation (NHIC), established on the basis of the provisions of Article 36 Paragraph 3 of the Constitution which stipulates health obligations to the people of the country and the National Health Insurance Act, contributes to the improvement of the health of the people with a set amount of funds. However, in reality, the National Health Insurance Act requires that the NHIC and the patient shoulder the cost of all medical services, while the NHIC and the NHS Act define work and daily medical activities as non-wage and place them in a private self-governing area where patients and medical institutions can perform medical activities in accordance with the agreement between the patient and the institution, and pay the entire cost of medical treatment. As above, patients have personally signed insurance contracts with insurance companies to guarantee their medical expenses to private insurers because the corporation guarantees not all but partial medical expenses, and the patients must pay the rest. Currently, about two-thirds of the nation s people are subscribed to loss insurance, suggesting that although it is not compulsory, it must be an essential insurance policy given its role in improving people’s health nationwide. Meanwhile, as the government implemented a policy to expand the coverage of health insurance, non-wage benefits were reduced from health insurance and medical institutions gave excess medical treatment in loss insurance as a target. The medical community s interest in generating revenue by providing excessive medical and random benefit care align with patients interest in actively using such over and excessive medical care and random benefit care, resulting in a rapid rise of insurance coverage and subsequently leading to an even more serious situation. Such moral hazard, done little by little among medical institutions and patients, will eventually return to the burden of other good policyholders and the entire public, not just the insurers. Based on these problems, this paper focuses on how to recover the random non-benefit medical expenses paid by the loss-making health insurer to the insured patient from the medical institution. First, check whether an insurer can claim damages against a medical institution for the cause of the illegal act. The appeal of the decision denied responsibility for illegal activities on grounds that there was no causal relationship between the actions of the medical institution and the loss of the insurer. However, the causal relationship cannot be denied, given the large number of lost-loss insurance subscribers and given that the medical institution can fully recognize that the patient who received the medical treatment will be charged for the loss-making medical expenses, such as issuing various documents necessary for the claim for loss-making insurance. In this respect, it is difficult to agree on the appeal conclusion of the target judgment. Next, it is necessary to consider actively exercising on behalf of the insured s rights, which are directly patients, on the basis of creditor rights. In this vein, there is a limited interpretation on the creditor s right to use it only when the debtor s responsible property does not have sufficient resources to reimburse them as an aid to the execution of the debtor s obligation, referring to the dynamic limit of creditor s authority. However, the Supreme Court and the Japan s Supreme Court ruling have recognized the independent function of the creditor s authority and, in certain cases, can be acknowledged regardless of the debtor s ability to repay or hold responsible property. This judgement is not considered to differ based on whether a creditor s bond is a specific commodity bond or a monetary bond. In this case, the issue was whether the money paid to the medical institution through the insurer, which had been directly paid by the insured who is the patient, should be returned dir

한일 의료보험법제의 동질성과 차이

홍성민(Hong, Songmin) 충남대학교 법학연구소 2017 法學硏究 Vol.28 No.1

일본에서는 의료보장과 관련하여 모든 국민이 공적의료보험제도 중 어느 하나에 의무적으로 가입하여 보장을 받을 수 있는 전국민개보험체제를 확립하고 있다. 이와 같은 “보편주의(평등주의)적인 일본의 의료보험제도는 지금까지 국민의 의료접근을 용이하게 하여, 국민의 수진기회의 평등보장에 있어서 큰 역할을 해 왔을 뿐만 아니라 현재까지 일본 의료보장의 근간을 이루는 제도로서 유지되어 왔으며 이는 가장 기본적인 특징”으로 평가되고 있다. 사회보험방식에 의한 공적의료보험제도를 가지고 있는 우리나라도 일본과 동일하게 전국민개보험체제를 이루고 있다. 이와 같은 우리나라의 의료보험제도에 관해서는 국민건강보험법이 규율하고 있으며, 해당 법률에 의하여 피보험자의 강제가입, 소득수준에 따른 보험료의 차등부과, 현물급여를 기본으로 하는 균등한 보험급여, 민간병원이 비율이 높은 가운데 요양기관의 당연지정제도 등을 규정하고 있다. 헌법재판소는 요양기관의 당연지정제도가 문제가 된 사건에서, “우리의료보험제도는 법률에 자격이 정해진 자가 보험료를 낼 것을 전제로 하여 보험급여를 하는 사회보험방식을 택하고 있다. 소득재분배와 위험분산의 효과를 거두려는 사회보험의 목표는 임의가입의 형식으로 운영하는 한 달성하기 어려우므로, 피보험자에게 가입의무를 강제로 부과하는 것은 의료보험의 목적을 달성하기 위하여 적합하고도 필요한 조치로써, 이로 인한 피보험자의 기본권에 대한 제한은 원칙적으로 정당화된다. 그런데 우리 의료보험제도는 피보험자인 국민뿐이 아니라 의료공급자도 또한 의료보험체계에 강제로 동원하고 있다. (중략) ‘요양기관 강제지정제’의 목적은 법률에 의하여 모든 의료기관을 국민건강보험체계에 강제로 편입시킴으로써 요양급여에 필요한 의료기관을 확보하고 이를 통하여 피보험자인 전 국민의 의료보험수급권을 보장하고자 하는 것이다”고 판결하였다. 이에 본고에서는 사회보험방식에 의한 공적의료보험제도를 운영하면서도 특히 전국민개보험체제를 확립하고 있는 우리나라와 일본에서, 이와 같은 제도를 유지하기 위한 중요한 요소로 평가되는 ‘강제가입’과 ‘요양기관지정’, 나아가 관련문제로서의 ‘임의비급여(일본에서는 혼합진료)’를 소재로 하여 동질성과 차이를 비교 및 분석하였다. Japan has established the Universal Healthcare Insurance Coverage System that requires all citizens subscribe to at least one principle schemes of public medical insurance system. Allowing citizen’s easy access to medical services, Japan’s universal (egalitarian) medical insurance system has not only played a key role to guarantee equal rights to medical treatment but also sustained today’s Japanese healthcare foundation. Similarly, Korea has preceded the universal healthcare insurance coverage under the public medical insurance system bound by the social insurance program. Korea’s healthcare insurance legislation is regulated by the National Healthcare Insurance Act that enacts rules regarding compulsory subscription of insured, discriminatory imposition of insurance premium according to income level, equal insurance benefits based on wage in kind, mandatory designation of healthcare organization with high ratio of private medical facilities, etc. The Constitutional Court reached a verdict related to designation of insurance medical facility that “Our Healthcare Insurance Legislation has chosen social insurance system assuming that insurance premium will be covered by those arranged by laws. The aim of social insurance based on allocation of income and risk is difficult to achieve with optional entry system, thus joining obligation is an appropriate measure and a justified violation of insured’s basic right. Yet, our medical insurance system also requires medical suppliers into service (….) the purpose of ‘designation of insurance medical facility’ is to secure sufficient number of necessary medical facility by legitimately including all medical facilities into national healthcare insurance system in order to guarantee all citizens’ rights to access to medical insurance.” Hence, this study compared and analyzed the similarities and differences Korea and Japan’s ‘compulsory subscription’ ‘designation of insurance medical facility’, and further related ‘arbitrary uninsured benefits’ that are critical features to maintain public medical insurance system bound by the social insurance program and to establish the universal healthcare insurance coverage system.

지역의료보험(地域醫療保險) 재정지출(財政支出)의 결정요인(決定要因)

감신,박재용,예민해,Kam, Sin,Park, Jae-Yong,Yeh, Min-Hae 대한예방의학회 1995 Journal of Preventive Medicine and Public Health Vol.28 No.1

This study was conducted to examine the determinant factors for expenditure of the medical insurance program for self-employeds based on the analysis of 1991 'The Medical Insurance Program for Self-Employeds Statistical Yearbook', and also similar yearbooks in the metropolitan and other provinces. The major findings are as follows : We have divided benefits into these four components such as the utilization rate for out-patients, expenses per claim for out-patients as paid by the insurer, utilization rate for in-patients, and the expenses per claim for in-patients as paid by the insurer, in order to examine the determinant factors for it. The results of the study revealed the following findings, in urban areas, the supply of medical care had more influence on the benefits than other demographic and economic variables, while, in county areas, both the supply of medical care and the rate of those aged over 65 affected the provision of benefits. The determinant factors for financial balance of the medical insurance program for self-employeds are, first, the determinant factor for administrative expenses was the number of households. The more the number of households, the less the administrative expenses per the insured. This shows that the economy of scale is being. And so, the administrative district must be taken into consideration in the incorporation of small regional medical societies and should be re-organized for more efficient management. Second, in urban areas, the supply of medical care had more influence on utilization rate and expenses per claim as paid by insurer, and therefore it is necessary to control it. In county areas, the supply of medical care and the rate of those aged over 65 raised the utilization rate and expenses per claim as paid by insurer. For the financial stability of county areas, a common fund for medical care for the aged and expansion of finance stabilization fund would be necessary. But, in county areas, it would be unnecessary to control the supply of medical care because it was much more insufficient than in urban areas. The vitalization of public health facilities must be carried out in county areas, for they reduced benefits. Sice the more insured in a single household, the less the utilization of the medical insurance program, benefits for habilitation at home should be given consideration. The law of majority and the economy of scale were applied here, and therefore the incorporation of regional medical societies must be taken into consideration. In integrating regional medical societies, it would be absolutely necessary to review the structural differences among all regional medical societies, the medical demand of each region, and also the local characteristics of each region.