현행 요양급여비용지급거부처분 관련 문제점과 개선방안 - 판례 법리를 중심으로 -

Essential medical services in Korea are said to be facing a crisis of collapse. At the root of this crisis lie not only issues related to inadequate reimbursement rates, but also structural problems inherent in the current system governing the denial of reimbursement for health insurance-covered services. This paper examines the legal issues surrounding the current denial system for health insurance reimbursements and proposes measures for its improvement. Currently, Korean courts treat the application for and adjustment of health insurance reimbursements as beneficial administrative acts. As a result, the burden of proof is placed on medical institutions to demonstrate that the medical services provided meet the criteria for insured benefits under the National Health Insurance regulations. Furthermore, institutions are also required to prove that the treatment corresponds to the “optimal treatment method” under Appendix 1 of the relevant enforcement rules. However, health insurance reimbursements serve not only as compensation for services already rendered under the National Health Insurance Act but also as a mechanism for cost recovery. Denial of such payments leads to direct financial losses for medical institutions. Nevertheless, the courts and the current system continue to impose a vague and subjective standard of “optimal treatment,” along with excessive evidentiary burdens, thereby effectively demanding undue responsibility and sacrifice from providers. and It is unreasonable to require physicians to provide the best possible care while simultaneously denying reimbursement merely because such treatment is not explicitly listed in the benefit criteria. When optimal care is provided, even if not strictly within the scope of the existing standards, reimbursement should still be granted. A system that imposes unilateral sacrifice on healthcare providers is unsustainable. True restoration of essential healthcare will only be possible when the system guarantees just and reasonable compensation for the services rendered by medical institutions.