Treatment is needed
The health plan will have to compensate the patient for denial of medication
Operators cannot exclude certain treatment when necessary for the health of the insured, as the health plan may limit the diseases covered, not the procedures, tests and techniques necessary to treat the disease included in the coverage list.
Judge Leandro Borges de Figuerredo of the 8th Brazilian Civil Court understood this by condemning a health insurance company to indemnify a patient who has denied medication deemed necessary for her treatment. The repair was set at $ 10,000. In addition, the judge ordered the carrier to provide the medication prescribed by the plaintiff's doctors.
“N.Since the disease affecting the author (cancer) is excluded from coverage, the health plan should not choose the best treatment, which depends on the attending physician. In addition, the contractual clause excluding drugs is abuse. Thus, the defendant is obliged to pay for treatment with the medicines recommended to the plaintiff, under the conditions prescribed in the medical report, which does not violate the ANS Resolution and the contract (Article 757 CC), ”he said.
In the trial of the case, the judge indicated that the relationship between the parties was civil and that, regardless of the discussion of the incidence or not of the Consumer Protection Code, it was not for the health plan to refuse to cover the most appropriate treatment of the patient. He also noted that the Supreme Court of Justice's humble understanding is that operators cannot exclude certain treatment when it is necessary for the health of insurers.
For the judge, the defendant's argument that the drug recommended to the author is excluded from the ANS list cannot be accepted because the list is “not exhaustive but exemplary, as well as the fact that the drug is not on the defendant's compulsory list; does not exempt her from providing the treatment prescribed by the patient's oncologist. “ With information from the press service of TC-DC.
Magazine Legal Adviser, November 17, 2019, 02:50 am