MEDICAL INSURANCE ACT

Article 1(Purpose) #

The purpose of this Act is to improve national health and promote social security by providing citizens with insurance benefits for disease, injury, childbirth, death, etc.

Article 2(Control) #

The medical insurance business as prescribed by this Act shall be controlled by the Minister of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995>

Article 3(Definitions) #

For the purpose of this Act,

1. the term “worker” means a person who lives on remuneration paid as compensation for his work, regardless of the category of occupation;

2. the term “employer” means an owner or operator of any business;

3. the term “workplace” means a business office; and

4. the term “remuneration” means any money, such as wages, salary, allowance, etc., paid to a worker as compensation for his work, except as prescribed by the Presidential Decree.

Article 4(Those Eligible for Insurance) #

(1) Those eligible for medical insurance under this Act shall be the insured workers of a workplace other than those eligible for medical insurance under the National Medical Insurance Act and their dependents: Provided, That those who are determined by the Presidential Decree shall be excluded. <Amended by Act No. 5489, Dec. 31, 1997>

(2) Deleted. <by Act No. 5489, Dec. 31, 1997>

(3) A dependent listed in paragraph (1) means a person who maintains his livelihood primarily through the insured, including the insured’s spouse, lineal ascendants (including his spouse’s lineal ascendants), lineal descendants, descendants’ spouses or brother and sister, and who meets the standards as determined by the Minister of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995; Act No. 5489, Dec. 31, 1997>

Article 5(Medical Insurance Deliberative Committee) #

(1) In order to deliberate the criteria for the medical care benefits as prescribed in Article 29 (3), the criteria for expenses related to medical care and childbirth benefits as prescribed in Article 35 (1), and main matters concerning other medical insurance business, and to provide any advice or suggestions as requested by the Minister of Health and Welfare, the Medical Insurance Deliberative Committee (hereinafter referred to as the “Deliberative Committee”) shall be established under the Ministry of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995>

(2) The Deliberative Committee shall be composed of the following members:

1. Members representing the insurers, the insured, and the employers;

2. Members representing the medical and pharmaceutical industries; and

3. Members representing the public interest.

(3) Matters necessary for the composition and operation of the Deliberative Committee shall be determined by the Presidential Decree.

Article 6 #

Deleted.<by Act No. 5489, Dec. 31, 1997>

Article 7 #

Deleted.<by Act No. 5489, Dec. 31, 1997>

Article 8(Continuous Voluntary Insurance) #

(1) If a person who is disqualified as an insured person under Article 10 (1) 3 files an application within fourteen days after he is disqualified, he may continue to be insured by the association to which he has belonged for up to one year from the date on which he is disqualified. <Amended by Act No. 5548, Jun. 3, 1998>

(2) The person eligible for continuous voluntary insurance as referred to in paragraph (1), shall be a person who has been insured by the association to which he has belonged for three or more months continuously up to the day preceding the day on which he is disqualified as an insured person.

Article 9(Time of Acquisition of Qualifications) #

(1) Any insured person under this Act shall obtain the qualifications from the date on which he is employed by a workplace listed in Article 4 (1) or from the date on which he no longer falls under the proviso of Article 4 (1). <Amended by Act No. 5489, Dec. 31, 1997>

(2) Deleted. <by Act No. 5489, Dec. 31, 1997>

Article 10(Time of Disqualifications) #

(1) Any insured person under this Act shall be disqualified on the day following the day on which he falls under any of the following subparagraphs: <Amended by Act No. 4856, Dec. 31, 1994; Act No. 5291, Jan. 13, 1997; Act No. 5489, Dec. 31, 1997>

1. When he dies;

2. When he loses his nationality;

3. When his employment relation is terminated;

4. When he falls under the proviso of Article 4 (1);

5. When he becomes a person to be under the medical care; and

6. When he is to be under the medical care as prescribed by the Act on the Honorable Treatment of Persons of Distinguished Services to Independence or the Act on the Honorable Treatment and Support of Persons, etc. of Distinguished Services to the State, and becomes excluded from the application of medical insurance as prescribed by this Act.

(2) Deleted. <by Act No. 5489, Dec. 31, 1997>

(3) Any continuous voluntarily insured person as prescribed in Article 8 shall be disqualified on the day following the day on which he falls under any of the following subparagraphs: <Amended by Act No. 5489, Dec. 31, 1997; Act No. 5548, Jun. 3, 1998>

1. When he dies;

2. When he loses his nationality;

3. When the continuous application period expires;

4. When he becomes insured by workplace as prescribed in Article 4 (1);

5. When he becomes insured under the National Medical Insurance Act;

6. When he becomes a person to be under medical care;

7. When the association is dissolved; and

8. When he fails to pay premiums by the time limit for the payment referred to in Article 56 (2).

Article 11(Confirmation of Acquisition and Forfeiture of Qualification) #

(1) The acquisition and forfeiture of the qualification for an insured person shall take effect by confirmation of the insurer, retroactively from the time when the insured acquires or forfeits his qualification under Articles 9 and 10.

(2) Any person who is or was an insured person may request the confirmation as referred to in paragraph (1).

Article 12(Insurer) #

(1) An insurer of medical insurance under this Act shall be an association. <Amended by Act No. 5489, Dec. 31, 1997>

(2) The association shall manage and operate the insurance of the insured.

Article 13(Organization of Association) #

(1) An association shall be organized with members who are employers and the insured employed in the employers’ workplaces. <Amended by Act No. 5489, Dec. 31, 1997>

(2) Deleted. <by Act No. 5489, Dec. 31, 1997>

(3) In the case of the association as referred to in paragraph (1), two or more workplaces may be organized jointly into one association. <Amended by Act No. 5489, Dec. 31, 1997>

(4) Deleted. <by Act No. 5489, Dec. 31, 1997>

Article 14(Legal Personality of Association) #

The association shall be a juristic person.

Article 15(Prohibition of Use of Similar Title) #

No person other than the association as prescribed by this Act may use the title of the medical insurance association or a similar one.

Article 16(Compulsory Establishment of Association) #

(1) Any employer of a workplace who employs the insured subject to compulsory application under Article 4 (1) shall prepare articles of association within such period as determined by the Presidential Decree, and establish an association with the authorization of the Minister of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995; Act No. 5489, Dec. 31, 1997>

(2) Deleted. <Amended by Act No. 5489, Dec. 31, 1997>

Article 17(Order to Establish Association) #

(1) The Minister of Health and Welfare may, if necessary, order any employers of two or more workplaces employing the insured to jointly establish one association. <Amended by Act No. 4972, Aug. 4, 1995; Act No. 5489, Dec. 31, 1997>

(2) The Minister of Health and Welfare may, if necessary, order two or more associations already established to jointly establish one association. <Amended by Act No. 4972, Aug. 4, 1995; Act No. 5489, Dec. 31, 1997; Act No. 5489, Dec. 31, 1997>

(3) The Minister of Health and Welfare may, if necessary, order any employer of a workplace who desires to establish an association under Article 16 (1), and an already established association, to jointly establish one association, or to transfer into an already established association. <Amended by Act No. 4972, Aug. 4, 1995; Act No. 5489, Dec. 31, 1997>

(4) Deleted. <by Act No. 5489, Dec. 31, 1997>

Article 18(Fictitious Application) #

Even in cases where workplaces having established an association under Article 16 (1), and workplaces of an association established under Article 17, do not fall under Article 4 (1), such workplaces shall be considered as those as prescribed in Article 4 (1). <Amended by Act No. 5489, Dec. 31, 1997>

Article 19(Establishment of Association) #

The association shall come into existence by obtaining authorization for its establishment, and making registration of establishment at the seat of its principal office, under the conditions as prescribed by the Presidential Decree.

Article 20(Modification of Articles of Association) #

(1) If the association desires to modify its articles of association, it shall obtain the authorization of the Minister of Health and Welfare: Provided, That this shall not apply to insignificant matters as determined by the Presidential Decree. <Amended by Act No. 4972, Aug. 4, 1995>

(2) If the matters as referred to in the proviso of paragraph (1) are modified, the contents thereof shall be reported to the Minister of Health and Welfare immediately. <Amended by Act No. 4972, Aug. 4, 1995>

Article 21(Officers and Workers, etc. of Association) #

(1) The officers of the association shall be a representative director, directors and auditor.

(2) The staff of the association shall be appointed and dismissed by the representative director, and matters necessary for the selection of officers and the appointment and dismissal of the staff shall be determined by the Presidential Decree.

Article 22(Designation of Agent) #

The representative director of the association may designate an agent from among directors or staff of the association, to act for him in regard to all the judicial or extrajudicial matters concerning activities of the association.

Article 23(Order to Dissolve Association) #

If it is deemed that any resolution of the association or any act of an officer of the association is contrary to Acts and subordinate statutes or articles of association, or to any measure taken by the Minister of Health and Welfare under this Act, and it is or might be prejudicial to the interest of members, or that it is difficult to continue the activities of the association in consideration of the activities or property situation of the association, the Minister of Health and Welfare may revoke such resolution, dismiss any officer, cancel the commission as a member of the operating committee, or order a dissolution of the association. <Amended by Act No. 4972, Aug. 4, 1995>

Article 24(Status of Officers and Staff of Association) #

Officers and staff of the association shall be regarded as public officials in the application of Articles 129 through 132 of the Criminal Act.

Article 25(Organization, etc. of Association) #

Matters necessary for the organization, management, operation, dissolution, merger, etc. of the association shall be determined by the Presidential Decree.

Article 26(Preventive Projects, etc.) #

The association may carry out preventive projects necessary for maintaining and promoting the health of the insured and their dependents.

Article 27(Medical Insurance Federation) #

(1) If it is deemed necessary for harmoniously carrying out the medical insurance business of the insurers, the Minister of Health and Welfare may order the associations or the National Medical Insurance Corporation established under the National Medical Insurance Act (hereinafter referred to as the “Corporation”), to establish the Medical Insurance Federation, which is an organization of insurers (hereinafter referred to as the “Federation”), or to join such Federation. <Amended by Act No. 4972, Aug. 4, 1995; Act No. 5489, Dec. 31, 1997>

(2) The Federation as referred to in paragraph (1) shall carry out any insurance financing stability projects to guarantee the stability of insurance financing of associations and the Corporation, and may establish and operate any medical or welfare facilities to promote the welfare of the insured and their dependents.

(3) In order to perform its functions, such as execution of the insurance financing security projects as referred to in paragraph (2), the Federation may collect such charges as determined by the Presidential Decree from the associations and the Corporation.

(4) The insurance financing stability projects as referred to in paragraph (2) shall be the following projects:

1. Projects as prescribed by the Presidential Decree, such as joint liability for high insurance benefits expenses;

2. Lending business for payment of expenses for the insurance benefits; and

3. Other projects necessary for the insurance financing security.

(5) Matters necessary for carrying out the insurance financing security projects as referred to in paragraph (2), shall be determined by the Presidential Decree.

(6) The provisions of Articles 14, 15, 19, 20, 22 through 26 and 80 shall be applicable mutatis mutandis to the Federation. In this case, the term “association” shall be read as the term “Federation”.

Article 28(Applicable Provisions) #

Except as provided by this Act, the provisions of the Civil Act concerning the corporate juristic person shall be applicable mutatis mutandis to the associations and the Federation.

Article 29(Medical Care Benefits) #

(1) The following medical care benefits shall be given for any disease or injury of the insured and their dependents:

1. Diagnosis;

2. Supply of medicine or materials for medical treatment;

3. Treatment, surgical operation and other medical care;

4. Hospitalization in medical facilities;

5. Nursing; and

6. Transportation.

(2) Except in cases where it is inevitable, the medical care benefits as referred to in paragraph (1) 1 through 4 shall be given in the following health or medical institutions or pharmacies (hereinafter referred to as “medical care institutions”):

1. Health or medical institutions or pharmacies designated by the insurer or organization of insurers; and

2. Medical care institutions established and operated by the organization of insurers.

(3) The criteria for the medical care benefits as referred to in paragraph (1), such as methods, procedures, scope, and maximum basis of such benefits shall be determined by the Minister of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995>

Article 30(Period for Medical Care Benefits Chargeable to Insurer) #

(1) The medical care benefit period in which the insurer bears the expenses shall be over three hundred days per annum, and such medical care benefit period shall be determined by the Presidential Decree: Provided, That the medical care benefit period is not restricted for persons falling under any of the following subparagraphs: <Amended by Act No. 4972, Aug. 4, 1995; Act No. 5291, Jan. 13, 1997; Act No. 5489, Dec. 31, 1997>

1. A person who is over sixty-five years of age;

2. A handicapped person who is registered under the Welfare of Disabled Persons Act;

3. A person of distinguished service to the State as prescribed in Article 4 (1) 4, 6, 10, 12 or 14 of the Act on the Honorable Treatment and Support of Persons, etc. of Distinguished Service to the State;

4. A person who has received medical care benefits for tuberculosis; and

5. A person who has received medical care benefits for such serious diseases as prescribed by the Presidential Decree.

(2) Notwithstanding the provisions of the text of paragraph (1), if the expenses of the medical care benefits borne by the insurer are under the amount as determined by the Minister of Health and Welfare, the insurer may extend the benefit period until the benefits reach such amount.

<Amended by Act No. 4972, Aug. 4, 1995>

Article 31(Delivery Benefits) #

(1) When an insured person or a dependent delivers a child at a medical care institution, the delivery benefits shall be given.

(2) The provisions of Article 29 (3) shall be applicable mutatis mutandis to the case as referred to in paragraph (1).

Article 32(Designation of Medical Care Institution) #

(1) The medical care institution as prescribed in Article 29 (2) 1 shall be designated by the insurer or insurers’ organization, under the conditions as prescribed by the Minister of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995>

(2) The insurer may delegate the authority to designate any medical care institution under paragraph (1), to the insurers’ organization.

(3) If it is required in designating the medical care institutions under paragraph (1), the insurer or insurers’ organization may designate them by classifying them into the first, the second, the third or special diagnosis and treatment institutions, under the conditions as prescribed by the Minister of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995>

(4) The Minister of Health and Welfare may, if necessary, have the insurer or insurers’ organization designate the medical care institutions. <Amended by Act No. 4972, Aug. 4, 1995>

(5) Any medical institution and pharmacy designated under paragraph (1) or (4) may not refuse it without any justifiable reason.

Article 33(Cancellation of Designation as Medical Care Institution) #

(1) The insurer or insurers’ organization may cancel the designation of medical care institution under the conditions as prescribed by the Minister of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995>

(2) The Minister of Health and Welfare may order any insurer or insurers’ organization to cancel the designation of a medical care institution if the medical care institution falls under any of the following subparagraphs: <Amended by Act No. 4972, Aug. 4, 1995>

1. Where any illegality is found in a request for the expenses of the medical care or delivery benefits under Article 35; and

2. Where the insurer or insurers’ organization violates an order issued under Article 76 (2), makes a false report, or refuses, interferes with, or evades any inspection or question of the public official concerned.

Article 34(Partial Liability for Expenses) #

(1) Any person who has received the medical care benefits as prescribed in Article 29 (1) or the delivery benefits as prescribed in Article 31 (1), shall bear part of such expenses under the conditions as prescribed by the Presidential Decree.

(2) The expenses to be borne by the insurer in the medical care benefits as prescribed in Article 29 (1) or the delivery benefits as prescribed in Article 31 (1), shall be the amount deducted from the partial charge as referred to in paragraph (1).

Article 35(Expenses, etc. of Medical Care) #

(1) The expenses related to the medical care or delivery benefits shall be the amount calculated on such basis as determined by the Minister of Health and Welfare through the deliberation of the Deliberative Committee. <Amended by Act No. 4972, Aug. 4, 1995>

(2) The insurer shall, upon receiving a demand for the expenses related to the medical care or delivery benefits from a medical care institution, examine and pay it under the conditions as prescribed by the Ordinance of the Ministry of Health and Welfare. However if it is found as a result of the examination that the amount of such part which the insured has already paid, is excessive the excessively paid-in amount shall be deducted from that to be paid to the medical care institution, and the remainder shall be returned to the insured: Provided, That this shall not apply where the amount to be returned is less than the amount as prescribed by the Presidential Decree, in the limit of one thousand won or less. <Amended by Act No. 4972, Aug. 4, 1995>

(3) If it is deemed necessary for the examination and payment as referred to in paragraph (2), the Minister of Health and Welfare may have the insurer carry out such affairs by entrusting another specialized institution with such affairs. <Amended by Act No. 4972, Aug. 4, 1995>

(4) Where the Minister of Health and Welfare entrusts affairs to another specialized institution pursuant to paragraph (3), he shall ensure that the independence and qualification of the specialized institution may be guaranteed. <Newly Inserted by Act No. 5489, Dec. 31, 1997>

Article 36(Expenses for Medical Care) #

(1) If an insured person or his dependent has received medical care in a medical care institution or at a pharmacy other than the medical care institutions as prescribed in Article 29 (2) due to an urgent or inevitable reason, the insurer shall pay him as medical care expenses the amount equivalent to the medical care benefits.

(2) A medical care institution, pharmacy, etc. having taken charge of the medical care as referred to in paragraph (1) shall deliver to the person who has received the medical care a statement of medical care expenses as prescribed by the Minister of Health and Welfare, or a receipt stating the details of medical care, and the said person shall present it to the insurer. <Amended by Act No. 4972, Aug. 4, 1995>

Article 37(Delivery Expenses) #

If an insured person or a dependent has delivered a child at a place other than the medical care institution as prescribed in Article 29 (2), the insurer shall pay her the delivery expenses as determined by the Minister of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995>

Article 38(Continuous Medical Care Benefits after Disqualification) #

(1) If an insured person who is receiving medical care benefits is disqualified as an insured person, and becomes an insured person by district under the National Medical Insurance Act, he may continue to receive such medical care benefits from the former insurer, with respect to his disease or injury, from the date on which the medical care benefits begin to be paid, to the date on which the medical care benefits period as prescribed in Article 30 expires. <Amended by Act No. 5489, Dec. 31, 1997>

(2) A person who is entitled to receive the benefits as referred to in paragraph (1) shall be the person who has been an insured person for one year or more consecutively up to the day preceding the date on which he becomes disqualified.

Article 39(Delivery Benefits after Disqualification) #

(1) If a person who was an insured person has delivered a child within three months after she is disqualified as an insured person, and becomes an insured person by district under the National Medical Insurance Act, she may receive the delivery benefits as prescribed in Article 31 or the delivery expenses as prescribed in Article 37 from the former insurer. <Amended by Act No. 5489, Dec. 31, 1997>

(2) The provisions of Article 38 (2) shall be applicable mutatis mutandis to the case as referred to in paragraph (1).

Article 39-2(Medical Examination) #

(1) The insurer shall conduct a medical examination for such insured person as prescribed by the Presidential Decree for the purpose of early discovery of disease and any medical care benefits incidental thereto.

(2) The frequency and procedure of the medical examination as referred to in paragraph (1), and other necessary matters, shall be determined by the Presidential Decree.

[This Article Newly Inserted by Act No. 4972, Aug. 4, 1995]

Article 40(Additional Benefits) #

In addition to the insurance benefits as prescribed by this Act, the insurer may pay the funeral expenses and other benefits as prescribed by the articles of the association, in conformity with the criteria as determined by the Presidential Decree.

Article 41(Restriction on Benefits) #

(1) If a person entitled to receive insurance benefits has caused an accident by his own offense or intentionally, the insurer shall not pay the insurance benefits.

(2) If a person entitled to receive insurance benefits fails to comply with any directive of the insurer or medical care institution as to medical care, without any justifiable reason, the insurer may refuse to pay all or part of the insurance benefits.

(3) If a person entitled to receive insurance benefits refuses to present any documents and other things as prescribed in Article 43, or evades any question or diagnosis without any justifiable reason, the insurer may refuse to pay all or part of the insurance benefits.

(4) If a person entitled to receive insurance benefits has received any medical care or medical care expenses pursuant to other Acts and subordinate statutes the insurer shall not pay the insurance benefits in the limit of such benefits.

(5) The insurer shall not pay the insurance benefits under this Act to a person who is to receive any insurance benefits or compensation as prescribed by other Acts and subordinate statutes due to any accident which has taken place in the course of his duty.

(6) If a person entitled to receive insurance benefits has received, or desires to have another person receive, the insurance benefits by a deceitful or other unlawful manner, the insurer may refuse to pay the insurance benefits within a period not exceeding three months.

(7) through (10) Deleted. <by Act No. 5489, Dec. 31, 1997>

Article 42(Suspension, etc. of Benefits) #

If a person entitled to receive insurance benefits falls under any of the following subparagraphs, the insurance benefits shall be suspended during such period:

1. When he is traveling overseas, or he is engaged in any business in a foreign country;

2. When he is in active military service; and

3. When he is confined to a prison or corresponding facility.

Article 43(Compulsory Diagnosis, etc.) #

If it is deemed necessary in granting the insurance benefits, the insurer may demand a person who receives the insurance benefits to present documents and other things, or have the person concerned undergo questioning or diagnosis.

Article 44(Payment of Medical Care Expenses) #

The insurer shall, upon request, pay without delay the medical care expenses, delivery expenses, or additional benefits.

Article 45(Collection of Unjust Enrichment) #

(1) Any insurer or insurers’ organization shall collect all or part of the amount equivalent to the insurance benefits or benefits expenses from a person who has received the insurance benefits, or medical care institution which has received the insurance benefits expenses, by a deceitful or any other unlawful manner.

(2) In the case as referred to in paragraph (1), if the insurance benefits have been granted by a false report or certification of an employer, or a false medical certificate of a medical care institution, the insurer may have such employer or medical care institution pay the amount to be collected under paragraph (1) jointly with the person who has received the insurance benefits.

Article 46(Claim for Compensation against Third Person) #

(1) If any insurer has paid the insurance benefits the cause of which occurred by an act of a third person, he shall obtain a claim for damages from the person who has received the insurance benefits, against the third person in the limit of the expenses needed for such benefits.

(2) In the case as referred to in paragraph (1), if the person entitled to receive the insurance benefits has already received compensation for damage from a third person, the insurer shall not pay the insurance benefits, in the limit of the amount of such compensation.

Article 47(Protection of Right to Benefits) #

The right to receive the insurance benefits shall be unalienable or unseizable.

Article 48(State Liability) #

The National Treasury may bear part of the expenses necessary for the operation of the medical insurance business on behalf of the associations or Federation thereof, within the limit of the budget each year, under the conditions as prescribed by the Presidential Decree.

Article 49(Premium) #

(1) In order to appropriate for the expenses needed for the medical insurance business, the insurer shall collect the premium from the person eligible for it under Article 52, from the month which includes the day on which he is qualified as an insured person to the month which includes the day preceding the day on which he is disqualified as an insured: Provided, That if he is qualified again as an insured in the month which includes the day preceding the day on which he is disqualified as an insured, the premium to be paid on the month in which he is qualified as an insured shall not be collected.

(2) The premium amount of the associations shall be the amount obtained by multiplying the standard monthly remuneration amount of the insured by the premium rate as prescribed in Article 51: Provided, That the premium amount of any continuously voluntarily insured person as prescribed in Article 8 shall be the monthly average amount of the premium amount imposed on the insured for the preceding two months, excluding the month which includes the day on which the relationship of employment is terminated. <Amended by Act No. 5489, Dec. 31, 1997>

(3) Deleted. <by Act No. 5489, Dec. 31, 1997>

(4) The premium of the insured who lives in or resides on islands or remote rural areas may be partially exempted under the conditions as prescribed by the articles of the associations.

Article 50(Standard Remuneration) #

(1) The standard monthly remuneration amount as prescribed in Article 49 (2) shall be calculated by grade on the basis of the monthly remuneration amount of the insured concerned.

(2) Matters necessary for calculation, etc. of the standard monthly remuneration amount by grade as referred to in paragraph (1) shall be determined by the Presidential Decree.

Article 51(Rates of Premium) #

(1) The premium rates of the associations shall be determined by the articles of the associations in the limit of 20/1,000 to 80/1,000. <Amended by Act No. 5489, Dec. 31, 1997>

(2) The premium rates of the associations for the insured who are engaged in any business overseas shall be determined separately by the Presidential Decree, but it shall be less than that as determined by the articles of the associations under paragraph (1). <Amended by Act No. 5489, Dec. 31, 1997>

Article 52(Liability for Premium) #

(1) The premium of the association shall be shared 50/100 by the insured in a workplace concerned and the employer who employs them, respectively: Provided, That the premium of the continuously voluntarily insured person as prescribed in Article 8 shall be borne in full by such insured. <Amended by Act No. 5489, Dec. 31, 1997>

(2) Deleted. <by Act No. 5489, Dec. 31, 1997>

(3) The premium of a continuously voluntarily insured person referred to in Article 8 shall be reduced by 50/100 if he meets the following requirements, and the ratio of the reduction shall be determined by the articles of an association: <Newly Inserted by Act No. 5548, Jun. 3, 1998>

1. He shall be a person who lost his job due to any managerial reason or the discontinuation or bankruptcy of his workplace referred to in Article 31 of the Labor Standards Act; and

2. He shall be a person whose application for a job referred to in Article 9 of the Employment Security Act has been accepted.

(4) A person who intends to have his premium reduced pursuant to paragraph (3) shall submit documents certifying that his application for a job issued by the head of an employment security agency referred to in Article 4 of the Employment Security Act has been accepted, to the association to which he belongs. <Newly Inserted by Act No. 5548, Jun. 3, 1998>

Article 53(Exemption from Premium) #

If a person falls under subparagraph 2 of Article 42, the premium shall be exempted.

Article 54(Liability for Payment of Premium) #

(1) The premium of the insured shall be paid by the employer: Provided, That the premium of the continuously voluntarily insured person as prescribed in Article 8 shall be paid by the insured. <Amended by Act No. 5489, Dec. 31, 1997>

(2) The employer shall deduct the premium amount to be borne by the insured in the current month from their remuneration. In this case, the insured shall be notified of such deducted amount. <Amended by Act No. 5489, Dec. 31, 1997>

Article 55(Premium Payment Term) #

(1) The premium of the insured shall be paid each month, but not later than the 10th day of the following month: Provided, That the continuously voluntarily insured person as prescribed in Article 8 shall pay in lump sum the premiums for the continuous application period within fourteen days after the relation of employment is terminated. <Amended by Act No. 5489, Dec. 31, 1997>

(2) Deleted. <by Act No. 5489, Dec. 31, 1997>

(3) Notwithstanding the provisions of the proviso of paragraph (1), any continuously voluntarily insured person may, on his own application, pay the premiums concerned by the following time limits: <Newly Inserted by Act No. 5548, Jun. 3, 1998>

1. Premium for a period of three months from the month following that which includes the date on which he acquires qualification (in case he acquires qualification on the first of a month, the month which includes the date on which he acquires qualification: hereinafter the same shall apply in subparagraph 2): within fourteen days from the date on which he acquires qualification; and

2. Premium for a period of more than three months from the month following that which includes the date on which he acquires qualification: the last day of the month preceding that in which a unit period, which spans a three-month unit period, starts.

Article 56(Demand for and Disposition for Failure of Payment of Premium, etc.) #

(1) If the premium or other money to be collected under this Act (hereinafter referred to as “premium, etc.”) has not been paid, the insurer or insurers’ organization may demand the payment thereof within a fixed time limit.

(2) In demanding the payment under paragraph (1), a demand notice shall be issued within a time limit for payment of not less than ten days, but not more than fifteen days.

(3) If a person who has received the demand as referred to in paragraph (1), fails to pay the premium, etc. by the time limit for payment, the insurer or insurers’ organization may collect it by the example of the disposition of national taxes in arrears, with the approval of the Minister of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995>

Article 57(Additional Dues) #

(1) If a person who is liable for payment of the premium, etc., fails to pay it by the time limit for payment, the insurer or insurers’ organization shall collect an additional dues equivalent to 5/100 of the premium, etc. in arrears, after the time limit for payment expires.

(2) If the premium, etc. in arrears is not paid within three months after the time limit for payment expires, additional dues equivalent to 5/100 of the premium, etc. in arrears from the day on which the period of three months expires, shall be collected by adding it to those as referred to in paragraph (1).

(3) If the premium, etc. in arrears is not paid within six months after the time limit for payment expires, additional dues equivalent to 5/100 of the premium, etc. in arrears from the day on which the period of six months expires, shall be collected by adding it to those as referred to in paragraphs (1) and (2).

(4) Notwithstanding the provisions of paragraphs (1) through (3), if a natural disaster or other inevitable cause as prescribed by the Ordinance of the Ministry of Health and Welfare occurs, the additional dues as referred to in paragraphs (1) through (3) may not be collected. <Amended by Act No. 4972, Aug. 4, 1995>

Article 58(Priority in Collection of Premiums) #

The premiums shall be collected in preference to other obligations, excluding national and local taxes.

Article 59(Calculation of Fractions) #

In calculating the premium, etc. and expenses for the insurance benefits, any fractions as prescribed in Article 1 (1) of the National Treasury Fractional Calculation Act shall not be calculated.

Article 60(Appeal) #

(1) Any person who is dissatisfied with a disposition on the qualification as an insured, premium, insurance benefits, or expenses for insurance benefits, may make an appeal to the Medical Insurance Appeal Committee (hereinafter referred to as the “Appeal Committee”).

(2) The appeal as referred to in paragraph (1) shall be made in writing within sixty days after the disposition is made, except where it is explained that it was impossible to make the appeal in such period for a justifiable reason.

Article 61(Second Appeal) #

Any person who is dissatisfied with the decision of the Appeal Committee as prescribed in Article 60 may make a second appeal to the Medical Insurance 2nd Appeal Committee (hereinafter referred to as the “2nd Appeal Committee). In this case, the provisions of Article 60 (2) shall be applicable mutatis mutandis to the second appeal.

Article 62(Establishment of Appeal Committee, etc.) #

(1) The Appeal Committee shall be established in the association which reviews and pays the expenses for insurance benefits or an insurers’ organization. <Amended by Act No. 5489, Dec. 31, 1997>

(2) The 2nd Appeal Committee shall be established in the Ministry of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995>

Article 63(Composition, etc. of Appeal Committee) #

(1) The Appeal Committee shall be composed of three members, representing insured, employers, and medical and pharmaceutical industry, respectively, and four members representing the insurers; and the 2nd Appeal Committee shall be composed of three members, representing the insured, the employers, the medical and pharmaceutical industry, and the insurers, respectively, and four members representing the public interest. <Amended by Act No. 5489, Dec. 31, 1997>

(2) The members of the Appeal Committee shall be commissioned or appointed by the head of the association or insurers’ organization, and those of the 2nd Appeal Committee, by the Minister of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995; Act No. 5489, Dec. 31, 1997>

Article 64(Term of Members) #

The term of members shall be three years, but where any public official becomes a member representing the public interest, it shall be the term of his office.

Article 65(Chairman) #

(1) The chairman of the appeal committee shall be the head of the association or insurers’ organization and that of the 2nd Appeal Committee, the Vice-Minister of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995; Act No. 5489, Dec. 31, 1997>

(2) If the chairman is unable to carry out his duties due to an accident, the member who is nominated by the chairman from among members representing the insurers, in case of the Appeal Committee, and from among those representing the public interest, in case of the 2nd Appeal Committee, shall act for him, respectively.

Article 66(Proceedings) #

(1) The meetings of the Appeal Committee (including the 2nd Appeal Committee; hereinafter the same shall apply) shall be convened by the chairman.

(2) The meeting of the Appeal Committee shall be held with attendance of a majority of all members, including at least one member representing the insured, the employers, the medical and pharmaceutical industry, the insurers, and the public interest (limited to the case of the 2nd Appeal Committee), respectively, and make a decision by a majority of members present. <Amended by Act No. 5489, Dec. 31, 1997>

Article 67(Powers of Appeal Committee) #

If it is deemed necessary for an appeal (including a second appeal; hereinafter the same shall apply), the Appeal Committee may have the person making the appeal (including the person making the second appeal; hereinafter the same shall apply) or interested person present necessary documents, state his opinion, make a report, or have a concerned expert make a diagnosis or examination.

Article 68(Decision on Appeal) #

(1) The decision on any appeal shall be made in writing.

(2) Matters decided by the Appeal Committee shall be effective as of the time a copy of such decision is served on the person making the appeal.

Article 69(Procedure, etc. of Appeal) #

Matters necessary for the operation of the Appeal Committee, and procedure etc. of the appeal, shall be determined by the Presidential Decree.

Article 70(Relation with Lawsuit) #

No appeal of dissatisfaction shall be instituted against the qualification as an insured person, premium, insurance benefits, or expenses for insurance benefits, without going through a decision of the 2nd Appeal Committee, except where three months have elapsed after the second appeal is made.

Article 71(Prescription) #

(1) If the right to collect the premium or to have it returned, the right to receive the insurance benefits or the expenses for insurance benefits, or the right to have the insured-borne charges paid in excess returned under Article 35 (2), has not been exercised for two years, the extinctive prescription shall be completed.

(2) The extinctive prescription as referred to in paragraph (1) shall be interrupted by any of the following causes:

1. Notice on and demand for the premium, etc.; and

2. Claim for the insurance benefits or expenses for insurance benefits.

(3) Except as provided otherwise by this Act, the extinctive prescription as referred to in paragraphs (1) and (2) shall be subject to the provisions of the Civil Act.

Article 72(Calculation of Period) #

Except as provided otherwise by this Act, the provisions of the Civil Act concerning the period shall be applicable mutatis mutandis to the calculation of the period as prescribed by this Act or any order issued under this Act.

Article 73(Protection of Rights and Interests of Workers) #

No employer of a workplace employing the insured as prescribed in Article 7 (1) may withhold a raise in pay or wage of the workers, discharge them, or take other unfavorable measures against them without any justifiable reason, with the intention of preventing them from becoming insured under this Act, or to evade any increase in the charges for which he is liable.

Article 74(Report, etc.) #

(1) The insurer may have any employer employing the insured report on the movement, remuneration, or income of the insured, or other matters necessary for the medical insurance business, or present any related documents, under the conditions as prescribed by the Ordinance of the Ministry of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995; Act No. 5489, Dec. 31, 1997>

(2) If it is deemed necessary to determine whether the report made or materials presented under paragraph (1) are true, the insurer may have staff under his control conduct an investigation on such matters.

Article 75(Furnishing of Materials) #

(1) An insurer and the Federation may request the State, local governments, other public organizations, etc. to furnish materials necessary for the medical insurance business.

(2) The State, local governments, other public organizations, etc. may not, upon receiving a request for materials under paragraph (1), refuse it without any justifiable reason.

Article 76(Report and Inspection) #

(1) The Minister of Health and Welfare may have an employer make a report on the movement and remuneration of the insured and other necessary matters, present related documents, have a public official under his jurisdiction ask any question to interested persons, or conduct an inspection on related documents. <Amended by Act No. 4972, Aug. 4, 1995>

(2) The Minister of Health and Welfare may have a medical care institution (including institutions which have provided diagnosis or medicine under Articles 36 and 37) make a report on the insurance benefits, such as diagnosis or supply of medicine, etc., order such institution to present related documents, or have any public official under his jurisdiction conduct an inspection or ask any questions. <Amended by Act No. 4972, Aug. 4, 1995>

(3) The Minister of Health and Welfare may have the person who has received the insurance benefits make a report on the particulars of such insurance benefits, or have a public official under his jurisdiction ask any questions. <Amended by Act No. 4972, Aug. 4, 1995>

(4) In cases as referred to in paragraphs (1) through (3), the public official concerned shall carry with him a certificate indicating his authority, and show it to the interested persons.

Article 77(Penalty, etc.) #

(1) If a person who is engaged in a medical care institution has unlawfully granted insurance benefits, or claimed expenses for insurance benefits in contravention of the criteria for the medical care benefits or calculation of medical care expenses, the Minister of Health and Welfare may make a disposition of suspension of licensed qualification for not more than one year. <Amended by Act No. 4972, Aug. 4, 1995>

(2) If a person who is engaged in a medical care institution has made an insurer, or an insured person and his dependent, bear unreasonably the expenses for insurance benefits due to the acts as referred to in paragraph (1), the Minister of Health and Welfare may order a suspension of the licensed qualification as referred to in paragraph (1), or impose a

penalty not exceeding ten times the expenses for insurance benefits which he has caused to be borne unreasonably. <Amended by Act No. 4972, Aug. 4, 1995>

(3) The penalty as referred to in paragraph (2), shall be collected by the Minister of Health and Welfare according to the examples of the collection of the national taxes, under the conditions as prescribed by the Presidential Decree. <Amended by Act No. 4972, Aug. 4, 1995>

(4) The detailed criteria for the disposition as referred to in paragraphs (1) and (2) shall be determined by the Ordinance of the Ministry of Health and Welfare. <Amended by Act No. 4972, Aug. 4, 1995>

Article 78 #

Deleted.<by Act No. 5453, Dec. 13, 1997>

Article 79(Maintenance of Secrets) #

Any insurer or person who is or was engaged in an insurers’ organization shall not divulge any secret which he has learned in the course of his duties.

Article 80(Supervision over Associations) #

The Minister of Health and Welfare may take any measures necessary for supervision, such as issuing an order to any association to make a report on its business or to modify its articles of association, after inspecting its business or the situation of its property. <Amended by Act No. 4972, Aug. 4, 1995>

Article 81(Delegation and Entrustment of Authority) #

(1) The authority of the Minister of Health and Welfare as prescribed by this Act may be delegated partially to the Seoul Special Metropolitan City Mayor, Metropolitan City Mayors, or Do governors, under the conditions as prescribed by the Presidential Decree. <Amended by Act No. 4972, Aug. 4, 1995>

(2) The authority of those of the Minister of Health and Welfare as prescribed in Articles 76 and 80, which concerns a demand to any medical care institution for presentation of materials related to the insurance benefits, or the direction and supervision over associations, may be entrusted to the Federation under the conditions as prescribed by the Presidential Decree. <Amended by Act No. 4972, Aug. 4, 1995>

Article 82(Entrusting of Operations) #

(1) The association may entrust postal service offices or financial institutions with operations concerning the receipt of premiums and payment for insurance benefits expenses pursuant to the provisions of the Presidential Decree.

(2) Deleted. <by Act No. 5489, Dec. 31, 1997>

Article 83(Special Cases for Workers of Foreign Governments and Foreigners) #

(1) The insurance benefits for workers in a workplace, the employer of which is a foreign government, may be prescribed separately by an agreement with the foreign government.

(2) Any foreigner as determined by the Presidential Decree may, on his own (meaning an insured who is a supporter in case of a dependent) application, be an insured or a dependent under this Act under the conditions as determined by the Ordinance of the Ministry of Health and Welfare. <Amended by Act No. 5548, Jun. 3, 1998>

Article 84(Penal Provisions) #

Any employer who violates the provisions of Article 73, or any person who violates the provisions of Article 79, shall be punished by imprisonment for not more than one year, or a fine not exceeding ten million won. <Amended by Act No. 5489, Dec. 31, 1997>

Article 85(Penal Provisions) #

Any person who violates an order referred to in Article 17 (2) and (3) shall be punished by imprisonment for not more than six months or a fine not exceeding five million won.

[This Article Wholly Amended by Act No. 5489, Dec. 31, 1997]

Article 86(Penal Provisions) #

Any person who violates the provisions of Article 15 (including where it is applicable under Article 27 (6)), 32 (5), or the former provisions of 36 (2), shall be punished by a fine not exceeding five million won. <Amended by Act No. 5489, Dec. 31, 1997>

Article 87(Joint Penal Provisions) #

If a representative of a juristic person, or an agent, servant or employee of a juristic person or individual commits an offense as prescribed in Article 85 or 86 in connection with the affairs of such juristic person or individual, the fine as prescribed in the respective Article shall be imposed on such juristic person or individual, in addition to a punishment of the offender.

Article 88(Fine for Negligence) #

(1) Any employer who fails to apply for the authorization for establishment within the prescribed period without any justifiable reason, in contravention of the provisions of Article 16 or 17 (1), shall be punished by a fine for negligence not exceeding 60/1,000 of the total of the insurable person’s remuneration for the delayed period.

(2) Any employer who fails to pay the premiums by the designated time limit for payment, in contravention of the provisions of Article 56, shall be punished by a fine for negligence not exceeding 20/100 of the premium amount to be paid.

(3) If a person who was an insured person or his dependent, receives, after he is disqualified, insurance benefits using any documents having certified his qualification, he shall be punished by a fine for negligence not exceeding the amount equivalent to such benefits.

(4) If a person who is entitled to receive insurance benefits has another person receive it by deceitful or other unlawful means, he shall be punished by a fine for negligence not exceeding the amount equivalent to such insurance benefits. In this case, the person who has received the insurance benefits by the same manner shall be subject to this provision.

Article 89(Fine for Negligence) #

Any person who falls under any of the following subparagraphs shall be punished by a fine for negligence not exceeding one million won: <Amended by Act No. 5489, Dec. 31, 1997>

1. A person who violates the provisions of Article 20 (including where it is applicable under Article 27 (6));

2. A person who violates an order issued under Article 80 (including where it is applicable under Article 27 (6)), or who refuses, interferes with, or evades, any inspection; and

3. A person who fails to submit documents, state his opinions, make a declaration or report , or who makes a false statement, declaration or report or refuses, interferes with or evades to an inspection in violation of Article 67, 74 (1) or 76 without any justifiable cause.

Article 90(Procedure for Imposition and Collection of Fine for Negligence) #

(1) The fine for negligence as prescribed in Articles 88 and 89 shall be imposed and collected by the Minister of Health and Welfare, under the conditions as prescribed by the Presidential Decree. <Amended by Act No. 4972, Aug. 4, 1995>

(2) Any person who is dissatisfied with the disposition of the fine for negligence as referred to in paragraph (1) may institute an objection against the Minister of Health and Welfare within thirty days after he is notified of such disposition. <Amended by Act No. 4972, Aug. 4, 1995>

(3) If a person who is subject to a disposition of the fine for negligence as referred to in paragraph (1) has made an objection under paragraph (2), the Minister of Health and Welfare shall without delay notify the competent court, which shall, upon receiving the notification, bring the case of fine for negligence to trial under the Non-Contentious Case Litigation Procedure Act. <Amended by Act No. 4972, Aug. 4, 1995>

(4) If no objection is made, and no fine for negligence is paid, within the period as referred to in paragraph (2), it shall be collected according to the examples of the disposition of national taxes in arrears.