Insurance coverage

STJ ruling may reduce health insurance coverage

São Paulo – The Supreme Court of Justice (STJ) will decide on Wednesday (23) whether or not health plans can be required to cover diagnoses, procedures and treatments not on a minimum coverage list established by the agency national health service for complementary health, RESPONSE. This is the case of examinations such as positron emission tomography, a type of tomography capable of diagnosing cancer and its stage of development, the use of video laparoscopy technology in various surgeries, hydrotherapy and other physiotherapies, the correction of myopia above 12 degrees, immunotherapy for the treatment of tumours, the so-called ABA therapy (Applied Behavioral Analysis) for autistic children, or again drugs against migraine, among others, are highly demanded in basic health plans.

“When you have cancer or a doctor recommends a test or procedure that is not on the ANS list, like cannabidiol for epilepsy for example, the solution is to take legal action. “Generally, the court recognizes that the old SLA list is a standard list. And that gives the health plan client a reason,” he said. RBA Journalist, writer and activist Andrea Werner, founder of Caterpillar Institute transforms into BUPA.

STF ministers will continue to rule on the so-called Divergence Ban, a set of actions taken by health plan customers who have declined cover for not being on the ANS list. In these, lawyers defend the thesis that the role is exemplary. In other words, its elements set an example of what should be guaranteed to customers in terms of health services. The case is so large that it has been declared by the court as having general implications.

Health and profit plans

In April 2021, in the midst of the most dangerous period of the covid-19 pandemic, the ANS proved that the list was exhaustive. So, health plans are now required to provide only what is on the list. With the change, there was more elimination.

“If they decide the exhaustiveness of the list, millions of Brazilians will suffer from a health handicap. There will be no longer any possibility of appealing to justice in the event of refusal to cover the agreement,” the activist said, noting that the dispute in question does not nullify the fight for the defense of the SUS, because the most affected part is working class.

Health plans say that if the STF decides the list is typical, it will make Brazil’s private health plans inaccessible to an even larger portion of the population. “Unlimited coverage eliminates cost predictability, which is essential to contract value, as well as completely incompatible with the sustainability of a system that seeks to provide better access to health for the population,” he said. written in a published article. Stadium Natalia Pompeo, legal director of the Brazilian Association of Health Plans (AFP).

economic dispute

However, the dispute is purely economic, according to activists from the Lagarta Vera Buba Institute, which is organizing a large demonstration this Wednesday in front of the STF, with the participation of entities from different regions of the country. “In the law, there is case law and the understanding that the good to be protected is life, and that seems to go without saying. Physicians and families are also in the best position to determine the best treatments, not health plans, which are put in place to provide complementary health to public health. RBA Me Vanessa Ziotti, Legal Director of the Institute.

As he remembers, companies interfere with treatments to achieve gains that can be achieved through other risk management models. They want to offer everything cheaper. This is what we saw with Prevent Senior in the event of a pandemic.

study ipea It showed that the per capita net income of health plans more than doubled between 2014 and 2018. In 2014, the total income was 123.8 billion reais, with growth despite a decline of around 3.3 million the number of users, which increased from 50.5 million in 2014 to 47.2 million in 2018.

As the 2018 values ​​are updated, it increased from R$75.7 in 2014 to R$185.8 in 2018. Net income doubled in real terms from R$3.825 billion $ to R$8.755 billion.

Read also

Health plans could see a record increase in 2022