Earticle

초록

영어

The Supreme Court stand in the position in specific lawsuit that it doesn't allow the discretionary not covered service, but recently in revocation suit of fine disposal that is imposed on medical fee of leukemia patient, it altered the existing adjudgement and admitted the discretionary not covered service exceptionally. It put forward the allowable condition roughly in that case. According as this alteration, it has become more important to embody the allowance conditions of exceptions. The Supreme Court presented three things, which are procedural condition, medical condition and subscriber's agreement. Concerning procedural condition, several present conciliation procedures are as follows: medical care benefit arret request, relative value conciliation etc, prior request on anti-cancer drug among chemicals which exceed acceptance criteria, request of non benefit object on common drugs. To be granted the existence of those system, there should be no obstacle to use that. Even if it were so, we should take circumstances into consideration; individual situation is unescapable concerning substance and urgency of the discretionary not covered service, process of the procedure, time required etc. Regarding medical condition, safety and effectiveness will be verified through evaluation procedures of new medical skill. About the necessity, the Supreme Court made clear through a sentence that it allow the discretionary not covered service, in case that needs to treat a patient out of the standard of medical benefit. Strict interpretation is right and it answer the purpose of the sentence that the supreme court permit the discretionary not covered service, exceptionally. We need to differentiate medical necessity and medical validity. Subscriber's agreement should holds true if it entails full explanation, and if it is preliminary, explicit and individual. On this account, it should be difficult to admit that someone agree effectively when he call for the affirmation that he is recipient of medical care. Reasonable expense needs to be a part of review whether the agreement is valid. Meanwhile If we adjust system of medical expense and eventually reorganize a fee for consultation payment system (Fee-for-service controlled by item to DRG (Diagnosis Related Groups)), controversial area of the discretionary not covered service will be decreased and that will guarantee the discretion of the doctor.

목차

I. 논의의 배경
 II. 국민건강보험제도에 대한 개략적 소개
  1. 국민건강보험제도의 의의 및 성격
  2. 요양급여와 요양기관
  3. 요양급여대상과 비급여대상
  4. 신의료기술평가
  5. 국민건강보험공단과 건강보험심사평가원
 III. 임의비급여의 정의 및 유형
  1. 임의비급여의 정의
  2. 임의비급여의 유형
 IV. 임의비급여의 허용조건-대법원판결이 제시한 요건의 구체화
  1. 임의비급여의 인정 필요성
  2. 대법원이 판시한 허용 요건
  3. 각 요건에 대한 구체적 검토
  4. 허용요건에 대한 증명책임
 V. 임의비급여 분쟁 해결을 위한 개선방안
 VI. 결어
 참고문헌
 ABSTRACT

키워드

저자

• 박태신 [ Park, Tae-Shin | 건강보험심사평가원 촉탁변호사, 법학사 ]

참고문헌

발행기관

간행물

표지보기 관심저널 등록

• 간행물명

  의료법학 [THE KOREAN SOCIETY OF LAW AND MEDICINE]

• 간기

  계간

• pISSN

  1229-8069

• 수록기간

  2000~2025

• 등재여부

  KCI 등재

• 십진분류

  KDC 517 DDC 613