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    政大機構典藏 > 法學院 > 法律學系 > 研究報告 >  Item 140.119/42957
    Please use this identifier to cite or link to this item: http://nccur.lib.nccu.edu.tw/handle/140.119/42957


    Title: 健保業務委外辦理之法律問題研究
    Authors: 劉宗德
    Contributors: 中央健康保險局;國立政治大學法律學系
    Keywords: 健保業務;委託民間辦理;健保局
    Date: 2000
    Issue Date: 2010-07-21 15:30:30 (UTC+8)
    Abstract: 本研究針對全民健康保險業務之特性,整理歸納其業務得委託進行之類型,分析委託之容許性與界限,探討其法律依據、委託方式及法律關係,進而依循現行法規範,架構全民健康保險業務委託民間辦理之程序規定、爭訟救濟途徑等制度。茲摘要內容如下:現行全民健康保險業務可歸納有﹕(1)繳款單、催繳函、異動清冊之列印及寄發業務﹔(2)投保單位成立申報表、保險對象異動表、中斷投保異議案件之資料登打﹔(3)一般健保業務之詢問、查詢、協助填寫表格﹔(4)為實施牙醫總額支付制度而將牙醫門診醫療服務點數之審查、統計以及品質監督等業務﹐委託中華民國牙醫師公會全國聯合會辦理﹔(5)就投保單位營業案狀況之實地訪查﹔(6)欠費案件之催繳及移送執行﹔(7)承保業務中涉及投保、退保、續保、停保、復保、變更事項等程序之審核、投保金額及保險費之核計、承保事項之查核及調查等(如查核保險對象之投保金額以多報少、保險對象未以適當身分加保案件等)﹔以及(8)配合新行政執行法之執行程序﹐有關欠費案件之催收及執行等業務等八類。其中﹐(1)∼(3)部分業務之委外﹐性質上屬於勞務採購﹐而有政府採購法規定之適用。其次﹐關於(4)之總額支付業務之委外辦理部分﹐依目前實務之作法﹐委託機關似僅為形式上之名義機關而該私人則為實質上之決定機關﹐宜有法規之授權或依據為宜,惟如僅係單純勞務、專業知識、技術、資訊服務之提供﹐而不涉及應否發動公權力行為之判斷或建議者﹐則與後述情形同﹐原則無須有法規之依據或授權。此時﹐因該委託業務多屬勞務採購性質﹐解釋上有政府採購法規定之適用。而(7)有關承保業務中涉及投保、退保、續保、停保、復保、變更事項等程序之審核、投保金額及保險費之核計之委託部分﹐其判斷標準亦與前述(4)部分同。亦即﹐如該等審核、核計等業務之實施﹐有明確標準而不涉及判斷者﹐原則無須有法規之依據或授權﹐且屬於勞務採購性質﹐而有政府採購法規定之適用。最後﹐關於(5)、(7)部分有關對投保單位之訪查及就承保事項之查核及調查等業務之委託﹐以及關於(6)、(8)催繳、移送等執行業務之委託部分﹐因多屬事後調查或僅為單純技術作業﹐不直接行使公權力﹐且受託人多非以自己名義實施委託業務﹐故原則上無須有法規之依據或授權﹐且因屬單純勞務採購性質﹐應有政府採購法規定之適用。至於健保業務委外辦理所生爭議之爭訟救濟途徑問題﹐其判斷標準原則上視該「委託關係」之性質如何而定。首先﹐關於委託機關與受託人之委託關係部分﹐其判斷標準與前述委託業務法律關係性質之判斷同﹐原則先認定有無政府採購法規定之適用﹐以決定得否適用政府採購法規定之調解、異議及申訴途徑。如該委託契約屬私法契約者﹐另有仲裁、民事訴訟途徑適用問題﹔反之﹐如屬公法關係者﹐則應考慮適用訴願、行政訴訟途徑。其次﹐關於受託人與第三人間就委託業務所生關係部分言﹐如受託人之行為視為委託機關之行為或直接對委託機關發生效力者﹐該第三人如屬被保險人、投保單位或保險醫事服務機構時﹐其救濟途徑原則得以委託機關為他方當事人﹐依健保爭議審議途徑解決﹔反之﹐如受託人之行為並不視為委託機關之行為或不直接對委託機關發生效力者﹐原則僅為受託私人與相對人間是否發生民事侵權行為問題﹐然仍應考慮有無國家賠償法規定之適用(如受託人構成行政助手情形)。最後﹐關於委託機關與第三人間就委託業務所生之關係而言﹐其情形同受託人與第三人間就委託業務所生關係部分說明。In the light of the unique characteristics of the national health insurance, this Project analyzed the legal issues regarding the contracting-out situations, which include: the legal permissibility, the legal basis, the methods, and the remedies. As to the pure ministerial matters such as typing, fact-finding, and format making, it is enough to apply the Government Procurement Act to deal with them in that the contracting-out thereof could be classified as pure procurement of service. Nonetheless, with respect to the matters involving public authority, discretion, or the policy choices, it is necessary to have the specific statutory authorization. For instance, the review and determination of premiums and the monitoring of services quality are more likely to be categorized as the latter. With regard to the legal remedies, the main criterion is the nature of the contracting-out. As to the controversy between the contracting agency and the contractor, the first step is to determine if the Government Procurement Act governs it. If the answer is affirmative, the demurring or complaint mechanisms provided by that Act could thus be utilized to resolve the relevant controversies. Secondly, it is necessary to determine whether the matter contracted out is private law or public law in nature. The private law controversy must be resolved by the arbitration or the civil procedure approach. By contrast, the matters which are public law in nature should be resolved through the administrative appeal and the administrative litigation procedures. As to the controversies between the contractor and the third party, the third party may list the contracting agency as direct opposite party in case that the contractor?H?Hs act was deemed the agency?H?Hs own acts. And the controversies thereof could be resolved through the approach provided by the National Health Act itself. On the other hand, if the contractor?H?Hs act was not regarded as the agency?H?Hs own act, the controversy between the contractor and the third party is the tort-like issue and should thus appeal to the civil procedure. But there is an additional concern: whether the contractor could be classified as exercising the public authority and the National Compensation Act would accordingly be applied.
    Relation: DOH89-NH-010
    應用研究
    委託研究
    研究期間: 8903~9004
    研究經費: 595 千元
    Data Type: report
    Appears in Collections:[法律學系] 研究報告

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