STJ: The Plan Cannot End the Case of a Seriously Ill Patient – 06/22/2022 – Daily Life

The second section of STJ (Supreme Court of Justice) It was decided Wednesday (22) that health plan operators who unilaterally terminate group contracts are obligated to maintain the bond of patients in hospital or patients undergoing treatment for critical illnesses.

The decision, which lower courts should follow in similar proceedings, says operators must ensure treatment continues until discharge from hospital.

We analyzed cases of a woman undergoing treatment breast cancer A minor with a chronic disease. They both went to court after the contract was suspended by Bradesco Saúde and were able to continue the coverage. The operator then appealed to the STJ, which has now standardized the understanding.

sought, Bradsko Side stated that it “does not comment on matters brought to court.”

The Rapporteur of the case, Minister Luis Philippe Salomao, noted that the law already prohibits plan operators health Under no circumstances should individuals terminate the contract while the user is in the hospital, and state that the understanding should extend to group plans.

“Beneficiaries cannot be excluded when they are receiving treatment for a serious illness or undergoing medical treatment that threatens their livelihood,” he said.

The thesis defended by the Rapporteur was that “the operator, even after the regular exercise of the right to unilateral termination of the collective plan, must ensure the continuity of the prescribed assistance care to the user in the hospital or in the full medical treatment which assures him of his survival or physical safety until discharge actual, provided that the bearer bears the full amount due.

The other ministers unanimously followed the vote for the rapporteur.

For Attorney General Sander Gomez Pereira Jr., of the Federal Public Defense Office, breach of contract cannot put users’ lives at risk.

“It’s a contract that is cut abruptly, with obvious damage both to the health and sometimes to the life of the beneficiary,” he said before the ministers’ vote.

In a recent decision, dated June 8, issued STJ Health plan operators have been released To pay for actions not included in your list of coverage ANS (National Agency for Complementary Health).

With the decision, for the benefit of companies, it was come to understand that the role of the ANS is taxationIt is not typical.

At that time, the court also understood that the operator was not obligated to pay for an action if there was a similar option in the ANS menu. If there is no therapeutic alternative, treatment indicated by the responsible health professional may be covered, on an exceptional basis.

Call List of health actions and eventsthe list defines the consultations, examinations, treatments and surgeries that constitute the mandatory coverage of organized health plans, that is, those contracted after January 2, 1999 or adapted to Law 9.656 / 98.

According to the ANS, the list currently has more than 3,000 procedures. All items must be guaranteed by the operators, under penalty of fines or suspension of marketing plans.