An exploration of the contract law principles inherent in the Health Care Insurance System and Long-Term Care Insurance System

2022 Fiscal Year Final Research Report

• Project/Area Number: 19K01329
• Research Category: Grant-in-Aid for Scientific Research (C)
• Allocation Type: Multi-year Fund
• Section: 一般
• Review Section: Basic Section 05040:Social law-related
• Research Institution: Niigata University
• Principal Investigator: ISHIGURO TSUYOSHI 新潟大学, 人文社会科学系, 准教授 (60400470)
• Project Period (FY): 2019-04-01 – 2023-03-31
• Keywords: 医療保険 / 診療報酬 / 公法上の契約 / 一部負担金

Outline of Final Research Achievements

This study clarified that the partial costsharing paid by the insured person should be interpreted as belonging to the Insurance Medical Care Facility (IMCF) at the time it is incurred, and that there is a specific connection between its legal nature theory and the contractual party theory. I also clarified the legal relationship surrounding the Examination and Payment Organization (EPO). First, after analyzing the contents of the consignment contract between IMCF and EPO, I showed that the initial attribution of medical fee claims is between IMCF and the insurer, which is concurrently assumed by EPO. The study also clarified that medical fee claims arise sequentially for each medical care service, but that they are consolidated at the time of billing by IMCF, and that the legal basis for consolidating them should be sought in the contract between IMCF and the insurer.

Free Research Field

民法

Academic Significance and Societal Importance of the Research Achievements

社会保険制度として展開されている医療保険や介護保険は、多くの国民に利用され、制度としては盤石なように見える。しかし、法的な視点からは、制度の中で誰が誰に対していかなる権利義務を有しているのかにつき、必ずしも意見の一致を見ない。本研究は、この問題について検討を加えることにより、社会保険制度に内在する契約の所在とその内容を明確化することを目的とした。本研究を通じて、各当事者の権利義務関係が明確化されると同時に、被保険者が支払うべき一部負担金の性質や内容、被保険者が支払わない場合（未収金）の法的対応、診療報酬債権の消滅時効の起算点など、社会保険を巡って実務上争われる諸問題の解決に資することになる。