社會醫療保障制度與民事損害賠償責任—論全民健康保險代位求償制度

Abstract

自全民健康保險法於民國84年公布施行以降，我國全民健康保險代位求償制度幾經修正，至今實施已逾30年載，為全民健康保險帶來不容小覷的保險費外收入。然而，關於現行求償制度之立法規定乃至於司法解釋，學說上多有批評，過去學說上討論重心，於求償法理基礎層面，多集中於保險法層次之利得禁止原則、損害填補原則；於具體規範層面，則集中於全民健康保險人應被允許對之代位求償之對象，以及求償範圍等等。至於超出這些傳統爭議之討論內容，則鮮少見得。 全民健康保險制度乃我國社會福利制度之一環，屬於立法者落實社會國原則之憲法基本原則的手段。是以，本文嘗試自更高層次之社會法補充性原則出發，追本溯源並重新建構全民健康保險對應負損害賠償責任第三人求償之法理基礎。同時使用比較法之研究方法，透過對日本、德國、英國、瑞典法律制度之介紹，探索實施社會醫療保障制度之其他現代國家，面對社會醫療保障制度所負社會給付責任與第三人民事損害賠償責任同時存在此一難題，各自採取怎樣的應對方法，最終歸納出「法定債權移轉—保險代位型」、「行政處分型」、「社會給付優先型」三種基本規範模式。 在對上述三類立法例之規範內容與運作框架具備基本的理解後，本文將進一步分析各種立法模式之優缺點，以及施行於我國可能面臨的問題暨法律制度上可能的回應，盡可能以最細緻、詳實的論理，評價、歸納出最適合我國全民健康保險制度之立法模式。 最後，於結論與建議部分，本文自全民健保求償規定於我國整體法規範體系應有的位置說起，其後進一步討論全民健保代位求償制度於實體以及程序規範二方面，各自應有如何之短期與長期修正目標。從而在貫徹補充性原則之要求，促進整體求償效益最大化，以增進國家公共利益之同時，亦能兼顧全民健保被保險人以及應負損害賠償責任第三人等利害關係人之私人利益，建構出符合社會整體最大利益之富有我國特色之全民健康保險代位求償制度。

Since the implementation of the National Health Insurance Act in 1995, Taiwan's National Health Insurance (NHI) subrogation system has undergone multiple revisions and has been in effect for over 30 years. This system has contributed significantly to the NHI’s non-premium revenue. However, both the legislative provisions of the current subrogation system and their judicial interpretations have faced considerable academic criticism. In the past, scholarly discussions on the legal foundation of subrogation have primarily focused on principles within insurance law. At the regulatory level, debates have centered on identifying the parties against whom the NHI should be allowed to exercise subrogation and the scope of such claims. The discussions beyond these traditional disputes, on the other hand, have remained scarce. The NHI system is part of Taiwan's social welfare framework and a means for lawmakers to implement the constitutional principle of a social state. This paper explores the legal basis for NHI’s subrogation claims against third parties liable for damages, using the higher-level principle of subsidiarity in social law. Through a comparative study of Japan, Germany, the UK, and Sweden, to show how modern countries address the coexistence of social healthcare benefits and third-party liability. Then, the study identifies three regulatory models: statutory claim transfer (insurance subrogation), administrative order, and social benefit priority. After establishing a basic understanding of the regulatory content and operational framework of the three legislative models, this paper will further analyze their strengths and weaknesses, as well as the potential challenges and possible responses in Taiwan. It aims to evaluate and identify the most suitable legislative model for Taiwan’s National Health Insurance system. Finally, in the part of conclusion and recommendations, this paper begins by examining the position of NHI subrogation provisions within Taiwan’s overall legal framework. It then discusses short-term and long-term reform goals for both substantive and procedural aspects of the subrogation system. By adhering to the principle of subsidiarity and maximizing overall claim efficiency, the aim is to enhance public interest while balancing the rights of insured individuals and third parties liable for damages. This approach seeks to establish a uniquely Taiwanese NHI subrogation system that aligns with the greatest overall social benefit.