The Superior Court of Justice (STJ) votes today to benefit or harm millions of health plan users.
The court will rule on appeals that prompted the review of the health insurance coverage rules, based on the list of procedures established by the ANS (National Supplementary Health Agency).
By Paulo Henrique Arantes, for 247 - The Superior Court of Justice could leave health plan beneficiaries in a state of helplessness this Wednesday (23). The court is judging today two appeals that motivated the review of the rule governing the coverage of diseases by health insurance plans, based on the list of procedures of the National Supplementary Health Agency (ANS). The trial began in September 2021, when Minister Luís Felipe Salomão voted for the taxativity of the list, that is, for the ANS list to cease being referential (or illustrative, in technical terms) and to become a maximum limitation of coverage. Thus, if Salomão's absurd interpretation prevails, anything not included in the list will not be covered.
“It will be very, very damaging to beneficiaries if the Superior Court of Justice (STJ) considers the ANS list as exhaustive, because the Agency has great difficulty in updating the list – it never keeps up with the evolution of medicine. It becomes very complicated to understand this list as an exhaustive list of coverage,” warns lawyer Marcos Patullo, a specialist in supplementary health and researcher at Cepedisa (Center for Studies and Research in Health Law).
In the first session of the trial, after Luís Felipe Salomão's vote, Minister Nancy Andrighi requested a review of the case. It is expected that her vote will differ from Salomão's. Last April, she considered any sub-legal norm that restricts treatment coverage for illnesses listed in the International Classification of Diseases (ICD) of the World Health Organization to be abusive, which now suggests her vote should not be exhaustive in the ANS list.
According to Andrighi, considering the list of procedures exhaustive would create "an unacceptable impediment to consumer access to the various treatment modalities for illnesses covered by the health plan and to new technologies that may emerge."
“The STJ’s decision will be quite important, because the vast majority of denials of coverage by health plans are based on the absence of the procedure in the ANS list. The court had an understanding, based on many years of experience, that this list is illustrative, meaning it does not exhaust the coverages that operators have to offer; it is merely a reference,” recalls Patullo.
"Those of us who work in this area are following this trial with great concern, because the decision could worsen the welfare rights of health plan beneficiaries," warns the lawyer.
The inadequacy of the ANS (National Supplementary Health Agency) list of covered services is notorious, and, if the STJ (Superior Court of Justice) follows Minister Salomão's recommendation, children, adolescents, and adults with rare or serious chronic diseases will be left unprotected. Mothers and caregivers of children with autism promise to demonstrate in front of the court today.
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