The consultant explains which unilateral resolution situations are legitimate or not; gives advice on reading contracts; and reveals the obligations of the operators
Recent cases of termination by the health service provider have raised alarm among the population. A bureaucratic issue full of small print that worries people about the risk of being caught by surprise by a termination of the contract. With this in mind, Elaine Souza de Oliveira, consultant at Nova Assist, summarizes the main points that plan users should know to protect themselves.
To begin with, Elaine explains that there are currently two types of health plans: individual and family plans (contracted by a single individual, with or without dependents) and collective plans (companies or associations, in which the employer or associate contracts for themselves, employees and dependents). “Individual or family plans can only be canceled in the event of non-compliance or fraud, according to current legislation,” explains the consultant.
Collective plans can be terminated unilaterally by the operator, provided that the termination conditions are set out in the operator’s service contract. “This information must be very clear, in accordance with Resolution 509 of 2022, of the National Supplementary Health Agency (ANS) and meet the minimum requirements for termination: minimum contract duration of 12 months and 60 days’ notice,” Elaine specifies.
When an operator can cancel someone’s plan:
There are variations depending on each company’s contractual model, but, in general, Elaine indicates the following as legitimate reasons:
- obtaining illicit gains in cases of fraud through reimbursement
- use of the plan with unproven clinical specificity that causes impacts and losses for the operator
- false information on clinical status
- irregular documents or false information at the time of hiring
- use of the plan by third parties or lending of the card
- Breaking of receipts or invoices
“In the event of default, the user must be without payment of the monthly fee for 60 calendar or cumulative days, but must be notified of the cancellation on the 50th day, generating the opportunity for payment or formalization of the cancellation by the operator,” adds Elaine, adding that the formalization to the consumer can take place online, digitally and in person, with due proof of receipt of the communication.
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When can’t the operator delete a customer?
Nova Assist adviser informs that the provider cannot disconnect a patient who is undergoing continuous medical treatment essential for his survival or for his physical and/or mental safety. “Even in cases of unilateral cancellation of the collective plan, the operator must guarantee the continuity of treatment until discharge, in compliance with law 9.656/98”, he informs.
Abusive termination conditions also include: unreasonable termination without contractual provisions; cancellations without granting a switch to another plan without a waiting period, an action that entails risks for consumers in a vulnerable position (people with palliative care, the elderly and disabled).
What should be given priority when reading the contract?
“The clauses regarding the conditions of use of the plan and those regarding the cancellation conditions are the most necessary,” explains Elaine.
It cites the Regulatory Resolution No. 509/2022 of the National Complementary Health Agency (ANS), which provides for the transparency of information and obliges operators to offer minimum mandatory information content.
“Many people end up not paying attention to the fact that the operator can withdraw from the contract unilaterally and without justification. That is why it is important to remember that all the information contained in the contract must be presented in a clear and objective manner to facilitate the consumer’s understanding”, the specialist guides.
Finally, Elaine informs that anyone who feels harmed by an unjustified cancellation should contact ANS on its digital channels.
Source: Elaine Souza de Oliveira, Nova Assist Consultant
Source: Terra
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.
