Did the health plan refuse service? See what to do in these cases

Published 09/05/2022 05:55 / Updated on 09/05/2022 05:56

(credit: Maurenilson Freire)

There is no doubt that a large part of the population considers Health is one of the most valuable “goods”. Some seek necessary care by contracting health plans. However, in some cases, what should be a hand on the wheel turns into a big hand Headache. But what can be done to guarantee rights in such cases? a Mail Heard experts on this topic.

a health plan contract Subject to the rules imposed by the Consumer Protection Act (CDC). In addition, the National Agency for Complementary Health (ANS) – linked to the Ministry of Health – is the body responsible for regulating, standardizing, controlling and inspecting activities related to private health care.

“Each articulated contract between individuals means autonomy of will—the freedom to contract, issuing rules that must be observed between the parties. In the case of a health plan contract, that contract does not have unrestricted autonomy. CDC and Law No. 9656, of 1998, which provide for private health care plans and insurance,” explains attorney Mariana Devisas, who specializes in consumer law and professor of law at the University of Brasilia (UnB).

With this, the consumer is given a range of services, says attorney Eldiser Amorim. He explains that “whoever rents a health plan has basic rights such as: consultations, exams, and procedures that depend on the category of contracted plan: outpatient, hospital (with or without obstetrics), referral or dental.”

Maria Soares, 69, a resident of Asa Sol, is one of the people having problems with the health care plan. The pensioner says her request was denied when she needed cataract surgery. “They said I wasn’t old enough, even though the surgery was low-risk,” he says. “I sent all the documents, but they denied it.” The elderly woman is still trying to appeal the decision and says her health has been affected by the problem. “The pain is only getting worse and they are not giving me an answer as to what I will do,” he is indignant.

shortage

Another point raised when talking about health plans is related to the grace period, which is a period in which the consumer, even after contracting the plan, is not entitled to a service related to some specific coverage. “The problem is that although a consumer is entitled to urgent or emergency care in the first 24 hours (Act 9.656/98, Section 12) after contracting a health care plan, operators limit coverage to only the first 12 hours, which is backed by the rules ANS – CONSU Resolution No. 13/1998 “, informs Ildecer.

However, for the insurance company to limit service deadlines, it must be informed in the contract, explained attorney Simone Magalhães, who specializes in consumer law. “The maximum grace periods stipulated in the legislation are: emergency and emergency – 24 hours (from 24 hours onwards, emergency and emergency care is mandatory, but the coverage rules must be observed for each type of contracted plan); delivery duration (one performed from the eighth week and the thirtieth gestation) – 300 days; other cases (such as consultations, exams, hospitalizations, surgeries) – 180 days ”, the specialist details.

Simon also talks about the issue of so-called pre-existing diseases and injuries (DLPs) – those that the consumer (or their legal guardian) knows about when contracting with the health plan. The consumer cannot refuse the contract for being in this state. But, upon request, you must inform the operator about those diseases that he knows about, as there are legal options to cover them.

The health fund operator may require medical examinations of the consumer to check for pre-existing diseases or injuries. If the request is not made and the consumer is not aware of its existence at the time of contracting, the plan cannot refuse coverage.

“As a general rule, the operator can refuse coverage for a pre-existing illness or injury within a period of up to 24 (twenty-four) months, if specified in the contract, in connection with more complex actions directly related to it, he explains. However, partial coverage must be provided. Consumer Provisional (CPT), which only includes low-complexity procedures, “must be included in the contract or in a contractual amendment which are very complex procedures that will not be fulfilled within a period of up to 24 months.”

Other actions, such as consultations and some tests, will be covered by the operator, depending on the type of plan contracted, after the grace periods have been met. Upon completion of 24 months of CPT, the plan must fully cover the pre-existing illness or injury.

According to the expert, another possibility provided by law is a “grievance” offer to the consumer, i.e. an increase in the monthly fee so that he is entitled to full coverage of the pre-existing illness or injury.

What is the tax role?

In addition to the time required to activate the plan, the type of service covered is also the subject of much debate, even in the legislative realm. Last Monday, the Senate approved a bill that would require health plans to cover services not on the ANS (Tax List), which currently includes 3,368 items. The text now goes to a presidential sentence.

“During this change, a citizen for whom a new treatment is indicated should seek an ANS, write a protocol, stating that the procedure is recommended by a national and global body for health technology. Effectiveness and scientific studies on this treatment. In other words, it is good to collect All this evidence so that the ANS sends the definition of a therapeutic resource to the health plan and enforces its implementation,” explains Daniela Torres, professor of the law course at Ceub who specializes in medical law.

Consumers whose rights have been violated can look for several ways to appeal the decision and make the health plan comply with what is required by law. “We have some non-judicial tools, like the Consumidor.gov portal, but the situation can be registered with the NSA itself and, as a last resort, a lawsuit can be filed,” Devisas says.

In the event of a violation of consumer rights, the company must compensate the health plan contractor. “The CDC guarantees as a fundamental right the effective repair of damages suffered by the consumer as a result of an action or omission on the part of the supplier (Section 6, 6), for example, any refusal to cover that causes disturbances or health problems,” explains Simon Magalhaes.

* Trainee under the supervision of Marcia Machado