• The Korean Society of Law and Medicine
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• v.8 no.1
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• pp.137-177
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• 2007

The medical expenses review system in Korea has developed under fee-for-service system with its own unique structure. The importance of reviewing medical expenses has been emphasized, as the size of medical expenditures moving through the health insurance legal context and its weight in the national economy have increased very rapidly. It is, however, analyzed that the feuds and arguments continue among the stakeholders for the lack of laws supporting the medical expenses review system. The medical expenses review is a series of administrative procedures, deciding whether claims from medical care institutions to the insurer are legal and valid or not. It mainly controls the increase of unnecessarily excessive health insurance claim and prevents fraudulent claim and abuse and checks the less use or unsuitable use of medical resources. It also works a function guarantees medical benefits for the appropriate treatment according to the object of health insurance system as a social insurance scheme. The dispute on legal base of the medical expenses review is about the source of law in the medical expenses review. There are the Health Insurance Act and administrative laws as jus scriptum and the guidelines of review as administrative orders. The medical expenses review should reflect various factors, such as the development of medical healthcare technologies, the health expenditures distribution, the financial situation of the health insurance, and the evaluation on the level of appropriate benefits. It is also likely to adapt to the traits of characters of medicine, and trends and transition, Besides it should judge the legality and the validity of medical benefits expenditures by synthesizing these all factors. And the evaluation system of appropriateness of medical benefits was administrative procedure which was consecutive with reviewing the medical expenses system and it was intended to make up for the result of reviewing the medical expenses in more comprehensive levels.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.11 no.8
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• pp.2876-2881
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• 2010

This paper attempts to find out implications based on the comparative analysis of overseas expansion model between the Korean insurance companies and the German one. There are three types of the strategies of the overseas-expansion-model of insurer, i.e. customer-oriented localized strategy, niche market-oriented strategy, and growing market-oriented strategy. From the review of related literatures and through an interview conducted by the insurance specialist, the findings are some differences between Korean and German insurance companies, when they go into foreign insurance markets. Th significant differences between Korean and German insurers are a customer oriented localized strategy and niche market oriented strategy. The Korean insurer shows a strength on the overseas-expansion-strategy, but the most clients of the Korean insurer on overseas markets are also Korean companies and Korean immigrants. The Korean legal expenses insurance market is yet in its embryonic stage, while the German legal expenses insurance company is pushing ahead with a strategy focused on localization and niche market on the legal expenses insurance product. In conclusion, like a case of the German legal expenses insurance company, the Korean insurer needs a customer oriented localized strategy as well as a niche market oriented strategy on the overseas insurance market.

• The Korean Society of Law and Medicine
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• v.14 no.2
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• pp.11-41
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• 2013

Article 347 of criminal law provides the act of deceiving another, thereby taking property or obtaining pecuniary advantage from another. On the other hand, the concepts of fraud and abuse are confused upon interpretation since the definition in National Healthcare Insurance Law is unclear, and it affects closely to the administrative measures such as surcharge levy by the period of inspection, therefore, the disputes continue in the forms of formal objection, administrative ruling and administrative litigation. This study aims to look over the legal problems on application of criminal fraud toward the abuse of 'Paid Medical Expenses(Article 57, Sections 1 and 4 of the National Health Insurance Act)'. The main issues are concept of abuse(Article 57, Sections 1 and 4 of the National Health Insurance Act), the problems of Directions of Health-Welfare Ministry on aspect of 'Nullum crimen sine lege' Principles, the proper sentenc-ing guidelines of fraud.

• The Korean Society of Law and Medicine
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• v.13 no.2
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• pp.45-72
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• 2012

The National Health Insurance Corporation has been retrieving from health care providers the payments made to them by insured patients as a result of the health care providers' arbitrary denial of coverage under the National Health Insurance, and has been disbursing such retrieved monies back to the patients, pursuant to Article 57, Sections 1 and 4 of the National Health Insurance Act. However, such practice is an application of the law that lacks legal exactitude. Another problem with such practice is that there is no legal provision under any laws or notices that expressly prohibits arbitrary denial of coverage. A legislative solution, therefore, is called for to address these issues.

• The Korean Society of Law and Medicine
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• v.16 no.2
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• pp.87-130
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• 2015

In a case in which National Health Insurance Corporation (NHIC) pays medical care expenses to a victim of a traffic accident resulting in injury or death and asks the assailant for compensation of its share in the medical care expenses, as the precedent treats the subrogation of a claim set by National Health Insurance Act the same as that set by Industrial Accident Compensation Insurance Act, it draws the range of its compensation from the range of deduction, according to the principle of deduction after offsetting and acknowledges the compensation of all medical care expenses borne by the NHIC, within the amount of compensation claimed by the victim. However, both the National Health Insurance Act and the Industrial Accident Compensation Insurance Act are laws that regulate social insurance, but medical care expenses in the National Health Insurance Act have a character of 'an underinsurance that fixes the ratio of indemnification,' while insurance benefit on the Industrial Accident Compensation Insurance Act has a character of full insurance, or focuses on helping the insured that suffered an industrial accident lead a life, approximate to that in the past, regardless of the amount of damages according to its character of social insurance. Therefore, there is no reason to treat the subrogation of a claim on the National Health Insurance Act the same as that on the Industrial Accident Compensation Insurance Act. Since the insured loses the right of claim acquired by the insurer by subrogation in return for receiving a receipt, there is no benefit from receiving insurance in the range. Thus, in a suit in which the insured seeks compensation for damages from the assailant, there is no room for the application of the legal principle of offset of profits and losses, and the range of subrogation of a claim or the amount of deduction from compensation should be decided by the contract between the persons directly involved or a related law. Therefore, it is not reasonable that the precedent draws the range of the NHIC's compensation from the principle of deduction after offsetting. To interpret Clause 1, Article 58 of the National Health Insurance Act that sets the range of the NHIC's compensation uniformly and systematically in combination with Clause 2 of the same article that sets the range of exemption, if the compensation is made first, it is reasonable to fix the range of the NHIC's compensation by multiplying the medical care expenses paid by the ratio of the assailant's liability. This is contrasted with the range of the Korea Labor Welfare Corporation's compensation which covers the total amount of the claim of the insured within the insurance benefit paid in the interpretation of Clauses 1 and 2, Article 87 of the Industrial Accident Compensation Insurance Act. In the meantime, there are doubts about why the profit should be deducted from the amount of compensation claimed, though it is enough for the principle of deduction after offsetting that the precedent took as the premise in judging the range of the NHIC's compensation to deduct the profit made by the victim from the amount of damages, so as to achieve the goal of not attributing profit more than the amount of damage to a victim; whether it is reasonable to attribute all the profit made by the victim to the assailant, while the damages suffered by the victim are distributed fairly; and whether there is concrete validity in actual cases. Therefore, the legal principle of the precedent concerning the range of the NHIC's compensation and the legal principle of the precedent following the principle of deduction after offsetting should be reconsidered.

• The Korean Society of Law and Medicine
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• v.8 no.2
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• pp.119-164
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• 2007

Improving the formal objection system regarding reviewing medical expenses requires authority and confidence in the aspect of well-functioning the health insurance review and assessment system, legally and appropriately. The purposes of improvement of the formal objection system should aim for protecting the people's right of health. On handling the formal objections, the disputes of the rights should be settled economically and promptly by fairness, specialty, and objectivity in the health insurance review and assessment administration. Therefore, in order to promote the administrative specialty of health insurance, the formal objection committee needs to be organized independently and guaranteed expertly. Under the current formal objection system, however, the organization of committee lacks right-relief function, recognition and public relation as a health insurance appeal system, and related professional man powers. It is also analyzed that there are several controversial points, such as mass deliberation to the formal objection committee and its conference procedure. As a measure of improvement, it is analyzed that the committee needs to be organized independently with a proper number of professional man powers. The strict deliberation procedures and the prohibition of the decision-making by non-conference are also required to be empowered. The formal objection procedure provides the beneficiaries and the claims legitimately, so that it secures the legal relations on the health insurance system. Therefore, on the conference process of formal objection, the expert and guaranteed protection should be provided promptly, and its procedures to the appellants should also be assisted kindly.

• Journal of Society of Preventive Korean Medicine
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• v.28 no.1
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• pp.13-30
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• 2024

Objectives : This study aimed to investigate the history, current status, and regulation of complementary medicine in Australia. Methods : To investigate complementary medicine in Australia, we searched domestic and overseas academic databases, and websites of public and private organizations related to the Australian health care. Results : Complementary medicine consists of numerous services, among which massage and chiropractic care are significantly utilized by Australians. Since 2010, Australian healthcare practitioners, in the field of complementary medicine, have been supervised by the Australian Health Practitioner Regulation Agency (AHPRA). Those who AHPRA is responsible for managing acupuncturists, chiropractors, and osteopaths. Other professions are regulated by their own respective associations. Not only aforementioned services offered by specialists, but also consumption of oral supplements accounts for considerable portion of complementary medicine in Australia. Complementary medicine products, vitamins, and minerals are managed by the Therapeutic Goods Administration (TGA). In terms of insurance policy, the reimbursement of complementary medicine expenses in Australia is covered by the public healthcare insurance system, Medicare. Medicare covers acupuncture, chiropractic, and osteopathy services. Other complementary therapies are continuously reviewed to update their coverage under this scheme. Conclusion : In Australia, practitioner qualifications, education standards, and scope of procedures related to complementary medicine are systematically managed through legal regulations of the federal and state governments.

• Proceedings of the KAIS Fall Conference
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• 2010.05b
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• pp.928-932
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• 2010

본 논문은 한국 및 독일 보험회사의 해외 진출 모델을 비교 연구한다. 특히, 독일 법률비용보험회사의 한국 진출 사례를 분석하여 국내 보험회사의 해외진출에 주는 시사점을 제시한다. 연구방법론으로서 한국 및 독일 보험회사의 해외 진출사례를 수집하여 비교 분석한다. 이를 위하여 각 보험회사의 해외진출 담당자와 면담, 이메일(e-mail), 전화상담 방법을 사용한다. 그리고 문헌연구를 통하여 연구의 이론적 배경과 기존의 연구결과를 분석한다. 본 연구에서는 보험회사 해외진출의 이론적인 배경으로서 고객지향 현지화전략, 수익지향전략, 신규특화시장 개척전략, 성장시장 진출전략 4개 요인으로 구분한다. 국내 보험회사는 해외 성장시장 진출 측면에서 긍정적인 반면에 수익지향, 현지화전략과 해외 신규 특화시장 개척 부분에서 아직 개선될 부분이 있는 것으로 분석되었다. 독일 보험회사는 한국 시장에 진출하면서 철저한 현지화전략, 특화시장 개척, 성장시장에 진출의 3개 부분에서 모두 긍정적인 것으로 분석되었다. 보험회사 해외진출의 이론적 배경 4개 요인을 적용하여 비교 분석한 결과 독일 보험회사의 사례와 같이 한국 보험회사가 해외에 진출할 경우에 보다 철저한 현지화 전략과 특화시장 개척 전략이 필요하다는 점을 제시한다. 본 연구의 한계점은 독일 법률비용보험회사 1개사를 대상으로 하고 있다는 점이며, 진출 초기라서 아직 경영실적이 뒷받침되지 않고 있다는 점이다. 향후 연구과제로서 일정시점이 지난 후에 국내 보험시장에서 독일 법률비용보험회사의 발전추이를 분석하여 시사점을 분석하고 법률보험시장에서 도덕적 위태 방지 연구, 소비자 보호를 강화할 수 있는 방안 연구를 향후 연구과제로 제시한다.

• Journal of Korea Port Economic Association
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• v.30 no.4
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• pp.111-130
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• 2014

The article 742(2) of the Korean Commercial Code allowed the third party to invoke a direct action against the insurer under a liability insurance. Meanwhile, the owners of the vessel enter into the P&I Insurance Contract with the P&I Club to indemnify all kinds of liability or expenses involved in the operation of its vessel. However, the Rule Book under the P&I Insurance mostly included the Pay to be Paid Clause which precludes the third party's direct action. Recently, the Seoul Central District Court passed a judgement on the validity of the Pay to be Paid Clause under the Korean law against the third party i.e. the cargo insurer having the right of subrogation. The court held that (1) the third party's right of direct action is not the right to claim insurance money but the right to claim damages against the P&I Club, (2) the insurer under a liability insurance is deemed to assume liability jointly and severally with the insured against the third party, (3) the Article 742(2) of the Korean Commercial Code is considered as a compulsory provision because it was invented to protect the innocent third party, the Paid to be Paid Clause is thus null and void. The purpose of this article is to evaluate the appropriateness of this court's judgments by comparative analysis of Korean and English law, and to suggest the relevant amendments of the Korean Commercial Code in order to prevent further legal disputes. The article criticizes the decision of the Seoul Central District Court, taking the attitude that, since the third party's right is the right to claim insurance money, the Paid to be Paid Clause is valid against the third party.

• The Korean Society of Law and Medicine
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• v.16 no.2
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• pp.159-193
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• 2015

Owing to causes such as population aging, increased use of various medical devices, long-term hospitalization of various patients with reduced immune function such as cancer, diabetes, and organ transplant patients, and the growing size of hospitals, hospital infections are continuing to increase. As seen in the MERS crisis of 2015, hospital infections have become a social and national problem. In order to prevent damage due to such hospital infections, it is necessary to first strictly implement measures to prevent hospital infections, while, on the other hand, providing proper relief of damage suffered due to hospital infections. However, the mainstream attitude of judicial precedents relating to hospital infection cases has been judged to in fact shift responsibility over damages due to hospital infections on the patient. In light of the philosophy of the damage compensation system, whose guiding principle if the fair and proper apportionment of damages, there is a need to seek means of drastically relaxing the burden of proof on the patient's side relative to conventional legal principles for relaxing the burden of proof, or the theory of de facto estimation. In relation to such need, the German civil code (Burgerliches Gesetzbuch), which defines contracts of medical treatment as typical contracts under the civil code, and has presumption of negligence provisions stipulating that, in cases such as hospital infections which were completely under the control of the medical care providers, if risks in general medical treatment have been realized which cause violations of the life, body, or health of patients, error on the part of the person providing medical care is presumed, was examined. Contracts of medical treatment are entered into very frequently and broadly in the everyday lives of the general public, with various disputes owing thereto arising. Therefore, it is necessary to, by defining contracts of medical treatment as typical contracts under the civil code, regulate the content of said contracts, as well as the proof of burden when disputes arise. If stipulations in the civil code are premature as of yet, an option may be to regulate through a special act, as is the case with France. In the case of hospital infection cases, it is thought that 'legal presumption of negligence' relating to 'negligence in the occurrence of hospital infections,' which will create a state close to equality of arms, will aid the resolution of the realistic issue of the de facto impossibility of remedying damages occurring due to negligence in the process of occurrence of hospital infections. Also, even if negligence is presumed by law, as the patient side is burdened with proving the causal relationships, such drastic confusion as would occur if the medical care provider side is found fully liable if a hospital infection occurs may be avoided. It is thought that, alongside such efforts, social insurance policy must be improved so as to cover the expenses of medical institutions having strictly implemented efforts to prevent hospital infections in the event that they have suffered damages due to a hospital infection accident, and that close future research and examination into this matter will be required.