Shall disputes between the Bureau of National Health Insurance and contracted healthcare providers arising from performance of the contract be regarded as a matter of public law nature and should the solution therefor follow the administrative litigation procedure?
Article 16 of the Constitution stipulates that the people's right of instituting legal proceedings should be guaranteed. Its aim is to ensure that when the people's rights are infringed upon, they may seek remedy by instituting proceedings pursuant to procedures set by the law. To exercise its authorized powers with respect to matters relevant to the administration of national health insurance, the Bureau of National Health Insurance, being a government organization pursuant to its organic law, enters into a National Health Insurance Healthcare Providers Contract with various healthcare providers appointing such providers as the providers of medical and healthcare services for the insured so as to achieve the administrative purposes of improving people's health and maximizing public benefits. For these reasons, the said contract has the nature of an administrative contract. Where the contracting parties disagree as to the provisions of the contract, it is a dispute under public law. According to Article 2 of the Administrative Proceedings Act amended and promulgated on October 28, 1998, "A dispute under public law, unless otherwise provided by law, may be instituted under this Act as an administrative litigation." Article 8, Paragraph 1, provides: "Where actions arise, under public law, between the people and the central or local authorities for payment of property or request for performance other than administrative acts, then proceedings for payment or performance may be commenced. The same applies to actions arising out of contracts governed by public law." Thus, when seeking relief, the procedures for administrative litigations shall be adhered to. Where a dispute arises regarding performance of the said contract between an insurance healthcare provider and the Bureau of National Health Insurance, and the healthcare provider has applied for a review in accordance with the procedures stipulated in Article 5, Paragraph 1, of the National Health Insurance Act but is not satisfied with the review, it may commence a proceeding for payment or performance pursuant to the laws.
Article 16 of the Constitution stipulates that the people's right of instituting legal proceedings should be guaranteed. Its aim is to ensure that when the people's rights are infringed upon, they may institute legal proceedings pursuant to procedures set by the law, and shall be entitled to fair trials and appropriate relief. Whether litigation of real cases should follow ordinary or administrative litigation procedures is an issue for the legislative body to decide, depending on the nature of cases litigated and the function of the existing litigation system. Adjudication of civil and administrative litigations in our State is to be carried out by courts of different nature according to the existing laws－ it being a dual system of litigation. Unless otherwise provided by law, all private law disputes shall be adjudicated by ordinary courts, while all public law disputes shall be adjudicated by administrative courts (See J.Y. Interpretation No. 466).
Within their lawful authority, administrative bodies may engage private citizens, by entering into administrative contracts, for the performance of specific services in order to achieve administrative objectives and facilitate the execution of duties of administrative bodies, and such bodies' shall bear the corresponding obligation of payment or performance (See Article 137, Paragraph 1, Subparagraphs 1 and 2, of the Administrative Procedure Act). For the purposes of administering national health insurance, providing health services and promoting the health of all citizens (See Article 1 of the National Health Insurance Act), Articles 3 and 6 of the National Health Insurance Act authorize the Department of Health of the Executive Yuan to set up the Bureau of National Health Insurance as the insurer to administer the National Health Insurance program. Further, Article 55 of the said Act permits the Bureau to enter into a National Health Insurance Healthcare Providers Contract with healthcare providers for the provision of clinical or hospital care services, by the healthcare providers pursuant to Article 31 of the said Act and the National Health Insurance Medical Benefit Regulations, in the event of illness, injury or maternity, to beneficiaries during the period of insurance. The services so provided are the basis for payment by the said Bureau (See Article 2 of the National Health Insurance Act). The compulsory insurance system adopted for the National Health Insurance program affects all the nationals' well-being to a great extent and falls within the public law arena. The foregoing has been explicitly explained in this Yuan's Interpretations Nos. 472, 473 and 524. By entering into the National Health Insurance Healthcare Providers Contract, the Bureau of National Health Insurance and the insurance healthcare providers covenant, on the part of the contracted healthcare providers, to provide medical services to the insured, and, on the part of the Bureau, to pay the approved service charges. Further, according to the provision in Article 1 of the said contract, the reason for payment by the Bureau is to promote national health and public benefits through the services provided by contracted healthcare providers, and they must comply with the laws of a public nature, i.e., the National Health Insurance Act and its Enforcement Rules, the Special Provisions and Management Rules for the National Health Insurance Healthcare Providers, and the National Health Insurance Medical Benefit Regulations, in their provision of healthcare services. To ensure fulfillment of contract obligations to perform medical services by contracted healthcare providers and their assistance in the said Bureau's administration of health insurance matters, the said contract allows the Bureau to set guidelines for the performance of the contract. In addition, as a means to achieve administrative objectives, the National Health Insurance Act provides the Bureau with authority to discipline contracted healthcare providers, placing one party to the contract, the Bureau, in a privileged position. Thus, this contract has the attributes of an administrative contract, and any dispute between the contracting parties regarding the contents of the contract shall be governed by public law. According to the Article 2 of the Administrative Proceedings Act amended and promulgated on October 28, 1998, "A dispute under public law, unless otherwise provided by law, must be instituted under this law as an administrative litigation"; Article 3: "Administrative litigations referred to in the preceding Article are proceedings for revocation, confirmation and payment or performance"; and Article 8, Paragraph 1: "Where actions arise, under public law, between the people and the central or local authorities for payment of property or request for performance other than administrative acts, then proceedings for payment or performance may be commenced. The same applies to actions arising out of contracts governed by public law," the system for instituting proceedings is complete. Where the applicant of this Interpretation, the contracted healthcare provider, disagrees with the Bureau of National Health Insurance over the contents of the said contract, it is a matter of public law and the applicant shall apply for a review in accordance with the procedures set forth in Article 5, Paragraph 1, of the National Health Insurance Act. It is only when the applicant is unsatisfied with the result of the review that an administrative litigation can commence pursuant to the law.
The National Health Insurance Act was enacted on August 9, 1994. Its Article 5, Paragraph 1, provides: "There shall be a Disputes Settlement Board established under the National Health Insurance program to settle disputes arising from cases approved by the Insurer, and raised by the insured, the group insurance applicants or the contracted healthcare providers." Paragraph 3 states: "The insured and the group insurance applicants may file administrative appeals and administrative litigations if they disagree with the Board's decision over the disputes in question." The remedy procedures to be followed in the event of the insurance healthcare providers' disagreement with the Dispute Settlement Board's decision are not explicitly stated. There is no disagreement that the Bureau of National Health Insurance and the contracted healthcare providers have agreed, in the said contract, to submit to the jurisdiction of the Civil Court. However, since the enforcement of the new administrative litigation procedures, the parties shall now seek resolutions using the procedures for administrative litigations. 'Translated by Wei-Feng Huang of THY Taiwan International Law Offices.