국민건강보험공단의 본인부담상한 초과액에 관한 법적 고찰 -대법원 2024. 1. 25. 선고 2023다283913 판결을 중심으로-

In October 2009, the standard terms and conditions were introduced for the first time in actual expense medical insurance, the excess amount according to the self-payment cap system implemented by the National Health Insurance Corporation is specified as not being covered by the insurance policy. However, disputes have arisen constantly as to whether or not the amount exceeding the upper limit is included in the compensation target of the actual medical expense insurance that was concluded before the amendment of the standard conditions, and the judgment has been diverged in the lower court. However, the Supreme Court recently clarified that even in the case of the so-called first-generation actual expense medical insurance, which was concluded before the revision of the standard terms and conditions, the insured person guarantees the part of the medical care benefit under the National Health Insurance Act that finally pays, and the amount refunded by the National Health Insurance Corporation in excess of the upper limit of burden is not covered. As a result, the insurance company can claim the claim for return of wrongful gain on the reimbursement paid by the National Health Insurance Corporation against the insured or the beneficiary who joined the first-generation actual expense medical insurance according to the Supreme Court's decision. Nevertheless, in practice, it will be very difficult for insurance companies to recover insurance money that have already been paid, and complaints will inevitably arise from the insurance consumer. In this case, unnecessary administrative costs or litigation costs will be incurred, and the money that can not be returned will be taken by the insurance company as a loss. There is a need to come up with a reasonable plan to flexibly solve these realistic problems. Although the plan to prepare the settlement procedure between the National Health Insurance Corporation and the insurance company that is currently being promoted is considered to be the most effective and feasible plan in reality, it should be accompanied by the maintenance of the related terms, laws and systems.