Patient receives compensation from health insurance plan.

TJDFT – In 2007, the patient was medically indicated for prostate surgery, but due to the delicate and traumatic nature of the treatment, he chose to postpone the surgery. In 2011, the examination revealed a worsening of the patient's condition, which is why a procedure using advanced technology, with the use of laser beams, a technique with rapid recovery, minimal bleeding, and no sequelae, was recommended.

However, Assefaz refused to authorize the laser procedure, arguing that the plaintiff's plan did not cover the surgery. The patient then underwent the procedure and paid all the expenses: R$ 5 for medical fees and R$ 7 for materials.

Assefaz argued that the surgical intervention was authorized using the conventional method, that is, without the use of special equipment. It maintained that the denial followed the regulations of the ANS - National Supplementary Health Agency, which does not include the mandatory authorization of surgical intervention using laser beams in its list of procedures.

The judge ruled that "the plaintiff is correct. The person qualified to determine the patient's needs, procedures, materials, and equipment is their attending physician. In this case, the documents point to these circumstances, making the defendant's refusal to cover the requested procedure unjustified. It was incumbent upon the defendant to provide evidence of the reasons used to refuse authorization, which it failed to do," she stated.

Regarding moral damages, the judge denied the request. "There is no doubt that the refusal to perform the surgery caused distress to the plaintiff, but in this specific case it did not reach the non-pecuniary sphere. Thus, the request for compensation for moral damages does not deserve to be granted," the judge said in her decision.

The decision is still subject to appeal.