국민건강보험법상 건강보험수급권의 제한과 조정

Abstract

The limitation and adjustment of the right on the health insurance in the National Health Insurance Act

Medical insurance benefits can not be provided if there is the reason that is prescribed in Article 48 of the National Health Insurance Act(NHIA) despite the fulfillment of the legal requirements to be received medical insurance such as diseases, injuries, childbirths, etc that is prescribed under Chapter Ⅳ in this Act. In the strict sense, the forms that Medical insurance benefit is suspended are divided into two classes. The first, the limitation of the right on the health insurance that is attributable to an wrong act of an insured. The second, the adjustment of the right on the health insurance that is attributable to the prevention of the excessive social benefit as a person who is eligible to receive a medical care benefit has received from the State or a local government an amount equivalent to the medical care benefit or become eligible to receive an amount equivalent to the cost of the medical care benefit under the provisions of other Acts and subordinate statute.

The limitation of the right on the health insurance means that a measure for disciplinary punishment that the subscriber have done wrong by turning the social responsibility into an individual personal responsibility. Then, this is divided into three classes. The First, insurance reason is caused by an individual wrong(clause 1-1 of Article 48). The Second, the failure in duty on the National Health Insurance Corp order or the organs of medical care order and cooperation(clause 1-2, 1-3 of Article 48). The third. the subscriber has neglected to pay the medical insurance premiums(clause 3, 4 of Article 48).

The limited system of insurance benefits when an insured has intentionally or through gross negligence caused a criminal conduct or intentionally contributed to the occurrence of an accident has the problem from the viewpoint of legal justification and the burden of proof. The first, Even though legal justification of the limitation of insurance benefits by the occurrence of an accident through gross negligence caused a criminal conduct is only found to the insurance policy, there is not much in a disciplinary measure. And the National Health Insurance Corp should prove to provide insurance benefits, but it is hard to prove of gross negligence. The second disciplinary measure is limited to all or nothing and this Act would never admit the discretion of the National Health Insurance Corp to settle the matter. With this situation, there are limits to considering the concretive validity needed for Social Security

This Act impose the duty of cooperation to a person who receives insurance benefits by being submit documents and other items or subject to questioning or diagnosis and this duty is embodid in clause 1-2, 1-3 of article 48. But the existing regulations is abstractive, comprehensive and then strict limitation of right would be seriously harmed. So this problem need to be considered in the construction of this clause.

There is a strong possibility that the right on the health insurance in the National Health Insurance Act is overlapped with right of benefits in other social security system. The reason is that the problem of health is not only a far-reaching influence upon the life-risk but also in principle National Health Insurance Act doesn't ask why the diseases occurred. In this case, the legal issue is that social security benefits would be excessively guaranteed and institutional apparatus such as clause 3, 4 of Article 48) is necessary to adjust this overlapping. Even though this clause fairly has the legal justification, there are some problem. First of all, this clause is provided in Article 48 with provision the limitation which is a completely different sphere from the limitation in terms of the legal character. And In this legislative method, it is hard to adjust the overlapping problem of various form in the social security system mutually, only raise a problem that is the too little guarantee and unnecessary trouble.

The purpose of this paper is to raise several problems about existing regulations regarding the limitation and adjustment of the right on the health insurance in the National Health Insurance Act and to develope legal interpretations from these. For this, this paper refer to judicial precedents, jurisprudence and compare these with those of foreign countries and to utilize them in the future legislative discussion for the matter mentioned above.

▣ Keywords : the limitation of the right on the health insurance, the adjustment of the right on the health insurance, medical care benefit, the social responsibility, the overlapping of benefit.