Operators can be sued to court if they fail to comply with the contract or regulatory agencies
Health plans have been the top target of consumer complaints for nearly a decade, according to a ranking released by the Brazilian Institute for Consumer Defense (IDEC). In 2022 it was no different: 27.9% of the services provided by the institute were related to situations involving operators of this type of service.
To help users plan, Luciana Roberto di Berardini, a lawyer specializing in consumer law and partner of Berardini Sociedade de Advogados, explains the most common questions and what is the best attitude in the face of these problems.
How do shortages for consultations and exams work?
The Resolution of the Federal Council of Medicine (CFM) n. 1.451 of 1995 defines “urgency” as “the unexpected onset of a health problem with or without potential risk to life, the bearer of which requires immediate medical assistance” and “urgency” as “medical detection of conditions causing of health”. involving imminent risk to life or intense suffering, thus requiring immediate medical attention”.
“A broken leg, for example, is an urgent situation. An acute myocardial infarction situation is an emergency,” explains Luciana.
With this in mind, the plan may apply grace periods for some treatments, as well as pre-existing illnesses.
“However, if one of these diseases worsens and becomes an emergency, even if it is a pre-existing disease, care must be taken,” informs the specialist.
The lawyer also points out that the person may need treatment for hypertension, but be without coverage for two years because it is a pre-existing disease: “But, if he has a spike in hypertension and, with that, a myocardial infarction acute, heart attack treatment cannot be denied, as this is an emergency and the grace period for emergencies is a maximum of 24 hours,” he advises.
What procedures should the plans cover?
After the grace period, the plan may refuse to cover a treatment based on evidence that it is ineffective.
Another important issue, underlined by Luciana, is that the health plan cannot choose how the treatment of a certain disease can take place, that is, it cannot limit a certain treatment in the contract.
“The plan can only determine what types of diseases it will treat, but if it excludes any disease it must be clear and objective about it,” emphasizes the specialist.
When to seek legal assistance to ensure treatment?
Luciana believes that it is ideal to go to court immediately after the plan has been denied to avoid worsening the patient’s condition, since, in many cases, it is not possible to wait months for a solution.
Exemplify using a case that had a recent decision: “In this trial, there was a refusal by the health plan to cover a medical procedure to treat the patient’s cancer. It was clear in the decision that the choice of how treatment would have been carried out is up to the doctor, never from the plan”.
When can tuition fees be considered abusive?
The abusive nature of the co-payment is generally linked to the lack of transparency regarding the amounts charged for the procedures performed.
“The health plan does not clarify how much was paid by the operator and what the patient’s share is due,” Luciana exemplifies.
As far as the monthly rents are concerned, the abuse occurs above all when there is an increase of 59 years, as the plans adjust the amounts more than what is contractually and/or authorized by the ANS.
In both situations, the orientation is to contact the plan so that both the costs of sharing and any abusive increases linked to the change of age are explained.
How to protect yourself from any dubious practices made by health plans?
“Doctors themselves can be good indicators of consumer rights in this case, as many times they already know that other patients have gotten a certain procedure/drug in court,” says the lawyer.
But, in case of doubt, it is always important to look for a specialized lawyer, who will be able to guide the consumer in the right and legal ways.
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Ben Stock is a lifestyle journalist and author at Gossipify. He writes about topics such as health, wellness, travel, food and home decor. He provides practical advice and inspiration to improve well-being, keeps readers up to date with latest lifestyle news and trends, known for his engaging writing style, in-depth analysis and unique perspectives.
