發文單位：司法院
解釋字號：釋字第533號
解釋日期：民國90年11月16日
解釋爭點：健保局與醫療機構履約爭議之救濟程序？
資料來源：司法院公報 第 44 卷 1 期 8 頁
                    司法院大法官解釋（十四）（99年5月版）第 325-336 頁
                    總統府公報 第 6435 號 22-31 頁
                    行政訴訟法實務見解彙編（96年12月版）第 6、106 頁

相關法條：中華民國憲法 第 16 條 ( 36.01.01 )
                    行政程序法 第 137 條 ( 90.06.20 )
                    行政訴訟法 第 2、3、8 條 ( 87.10.28 )
                    全民健康保險法 第 1、2、3、31、5、55、6 條 ( 90.01.30 )

解釋文：
憲法第十六條規定，人民之訴訟權應予保障，旨在確保人民於 其權利受侵害時，得依法定程序提起訴訟以求救濟。中央健康保險局依其組織法規係國家機關，為執行其法定之職權，就辦理全民健康保險醫療服務有關事項，與各 醫事服務機構締結全民健康保險特約醫事服務機構合約，約定由特約醫事服務機構提供被保險人醫療保健服務，以達促進國民健康、增進公共利益之行政目的，故此 項合約具有行政契約之性質。締約雙方如對契約內容發生爭議，屬於公法上爭訟事件，依中華民國八十七年十月二十八日修正公布之行政訴訟法第二條：「公法上之 爭議，除法律別有規定外，得依本法提起行政訴訟。」第八條第一項：「人民與中央或地方機關間，因公法上原因發生財產上之給付或請求作成行政處分以外之其他 非財產上之給付，得提起給付訴訟。因公法上契約發生之給付，亦同。」規定，應循行政訴訟途徑尋求救濟。保險醫事服務機構與中央健康保險局締結前述合約，如 因而發生履約爭議，經該醫事服務機構依全民健康保險法第五條第一項所定程序提請審議，對審議結果仍有不服，自得依法提起行政爭訟。

理由書：
憲法第十六條規定，人民之訴訟權應予保障，旨在確保人民於其權利受侵害時，得依法定程序提起訴訟並受公平審判，以獲得適當之救濟。具體案件之訴訟，究應循普通訴訟程序抑或依行政訴訟程序為之，應由立法機關衡酌訴訟案件之性質及既有訴訟制度之功能等而為設計。我國關於民事訴訟與行政訴訟之審判，依現行法律之規定，分由不同性質之法院審理，係採二元訴訟制度。除法律別有規定外，關於因私法關係所生之爭執，由普通法院審判；因公法關係所生之爭議，則由行政法院審判 之（本院釋字第四六六號解釋參照）。
        行政機關基於法定職權，為達成行政目的，得以行政契約與人民約定由對造為特定用途之給付，俾有助於該行政機關執行其職務，而行政機關亦負相對之給付義務（行政程序法第一百三十七條第一項第一款及第二款參照）。國家為辦理全民健康保險，提供醫療保健服務，以增進國民健康（全民健康保險法第一條參照），依全民健康保險法第三條、第六條規定，由行政院衛生署設中央健康保險局為保險人，以辦理全民健康保險業務，並由中央健康保險局依全民健康保險法第五十五條規定，與保險醫事服務機構締結全民健康保險特約醫事服務機構合約，於保險對象在保險有效期間，發生疾病、傷害、生育事故時，由特約保險醫事服務機構依全民健康保險 法第三十一條及全民健康保險醫療辦法，給予門診或住院診療服務，以為中央健康保險局之保險給付（全民健康保險法第二條）。按全民健康保險為強制性之社會保 險，攸關全體國民福祉至鉅，具公法之性質，業經本院釋字第五二四號、第四七三號、第四七二號解釋闡釋甚明。中央健康保險局與保險醫事服務機構締結之全民健 康保險特約醫事服務機構合約，該合約既係由一方特約醫事服務機構提供就醫之保險對象醫療服務，而他方中央健康保險局支付其核定之醫療費用為主要內容，且依 全民健康保險特約醫事服務機構合約第一條之規定意旨，中央健康保險局之費用給付目的，乃在使特約醫事服務機構依照全民健康保險法暨施行細則、全民健康保險 醫事服務機構特約及管理辦法、全民健康保險醫療辦法等公法性質之法規提供醫療服務，以達成促進國民健康、增進公共利益之行政目的。又為擔保特約醫事服務機 構確實履行其提供醫療服務之義務，以及協助中央健康保險局辦理各項保險行政業務，除於合約中訂定中央健康保險局得為履約必要之指導外，並為貫徹行政目的， 全民健康保險法復規定中央健康保險局得對特約醫事服務機構處以罰鍰之權限，使合約當事人一方之中央健康保險局享有優勢之地位，故此項合約具有行政契約之性質。締約雙方如對契約內容發生爭議，自屬公法上爭訟事件。依八十七年十月二十八日修正公布之行政訴訟法第二條：「公法上之爭議，除法律別有規定外，得依本法提起行政訴訟。」第三條：「前條所稱之行政訴訟，指撤銷訴訟、確認訴訟及給付訴訟。」第八條第一項：「人民與中央或地方機關間，因公法上原因發生財產上 之給付或請求作成行政處分以外之其他非財產上之給付，得提起給付訴訟。因公法上契約發生之給付，亦同。」等規定，訴訟制度已臻完備，本件聲請人特約醫事服 務機構，如對其與中央健康保險局所締結之合約內容發生爭議，既屬公法上事件，經該特約醫事服務機構依全民健康保險法第五條第一項所定程序提請審議，對審議結果仍有不服時，自得依法提起行政爭訟。
全民健康保險法制定於八十三年八月九日，其第五條第一項規定：「為審議本保險被保險人、投保單位及保險醫事服務機構對於保險人核定之案件發生爭議事項，應設 全民健康保險爭議審議委員會。」第三項規定：「被保險人及投保單位對爭議案件之審議不服時，得依法提起訴願及行政訴訟。」就保險醫事服務機構，於不服全民 健康保險爭議審議委員會審議結果，應循何種訴訟途徑救濟未設規定，中央健康保險局於前開全民健康保險特約醫事服務機構合約中與特約醫事服務機構合意定民事 訴訟管轄法院（本院釋字第四六六號解釋參照），固非可議，惟行政訴訟新制實施之後，自應循行政爭訟程序解決。

J. Y. Interpretation No.   533
Date：2001.11.16
Issue： 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?

Holding：
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.

Reasoning：
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.