Legal issues regarding the compensation for drug costs reimbursement under a risk-sharing agreement in actual expenses medical insurance : A review of the Supreme Court ruling 2024Da223949 announced on July 11, 2024.

Actual expense medical insurance, which compensates medical expenses due to the policyholder's injury or illness, does not merely remain within the area of moral hazard in the insurance, but rather causes side effects that result in a shortage of medical staff and distortion of the healthcare system due to the relatively low treatment of medical personnel engaged in essential medical fields, The court rulings that impose compensation responsibilities for amounts exceeding what the insured actually spends on actual expense medical insurance have contributed to this outcome. Therefore, it is necessary to limit the compensation under actual expense medical insurance to only cover the actual costs incurred by the insured, with certain restrictions on the scope of compensation as well. The Supreme Court ruling on July 11, 2024 (2024Da223949) stated that only the medical expenses actually borne by the insured are subject to compensation under the actual expense medical insurance contract, while amounts not actually borne do not qualify for compensation. This decision suggests a potential shift in the Supreme Court's stance regarding the actual expense medical insurance in the future. The Justices of the Supreme Court determined that “the refund received by the insured from the pharmaceutical companies under a risk-sharing system, which do not correspond to actual costs incurred by the insured, are not included in the amounts subject to insurance payment. Since the subject of insurance payments in the actual expense medical insurance pertains to financial loss, it is a general expectation in transactions that no gain beyond the compensation for the loss can be obtained. Therefore, if the insured receives a refund for part of the drug costs from a pharmaceutical company due to a risk-sharing scheme, that refunded amount should not be included in the compensation for damages, which is not subject to the duty of clarification or explanation. However, if only the parts that the insured actually incurs are deemed compensable, it raises a question whether, in cases where medical expenses are subsidized or discounted by the government's or companies' welfare programs, amounts not actually borne by the insured should similarly be excluded from compensation. The standard provisions of actual expense medical insurance state that if the insured receives a discount on medical expenses due to laws or from medical institutions, the calculation shall be based on the actual expenses borne after the discount. If the discounted medical expenses are included as labor income, the calculation for reimbursable medical expenses shall reflect the pre-discount amount according to 「Act on the Honorable Treatment and Support for Persons of Distinguished Service to the State」, 「Act on the Honorable Treatment of Persons of Distinguished Service to Independence」. Most real indemnity insurance contracts currently offered by insurance companies adopt the wording of these standard provisions. In situations where the insured receives discounts on medical expenses due to welfare programs, despite being the same in the financial expenditure perspective, they are viewed as not incurred in the case of reimbursements for risk-sharing drug costs, leading to exclusion from compensation, while discounted medical expenses due to welfare are treated as amounts actually borne by the insured and included in compensation. It is questionable whether this logic is consistent and socially equitable. Reimbursements for drug costs under risk-sharing contracts are an adjustment of medical fees, with the National Health Insurance Public Corporation having the authority to decide on medical fees under the law. The adjusted amount(reduced drug cost) through contracts between the National Health Insurance public corporation and pharmaceutical companies occurs within the framework of the National Health Insurance.