The fact that an exam is not included in the list of mandatory procedures of the National Agency for Supplementary Health (ANS) does not prevent it from being carried out by health plans, as the list is not exhaustive. This was the understanding of the 11th Civil Chamber of the Court of Justice of Minas Gerais (TJ-MG) when condemning an operator for refusing to cover PCR, IgG and IgM tests, which detect contamination by the new coronavirus.
According to the process, the author had symptoms of Covid-19 in June 2020. During the consultation, the doctor filled out a guide from the medical cooperative Unimed, requesting the exam. The patient went to the company’s administrative sector and was informed that the procedure could only be authorized by WhatsApp. Once the request was made via the application, the authorization was denied.
The user of the plan, fearing the risk to her own health and the possibility of infecting others, went to the Unimed Hospital, where she was consulted by another doctor. The professional, after examining the patient, filled out a second form requesting the Covid-19 test. The woman, however, was denied another request for authorization, with the justification that a note had been issued so that the doctors would not prescribe guides with the same content as the two that were received.
The woman sought another health plan and underwent the test, which was positive. So, she filed suit against Unimed and claimed that the denials had shaken her psychologically.
The company, in its defense, claimed that, according to the third guide issued by the physician, the patient had already had the new coronavirus and, even so, requested another PCR test, as well as IgG and IgM. According to the company, the IgG and IgM serological tests, at the time, had not yet been authorized by the ANS. This only occurred on August 13, 2020. Thus, on the date of application, Unimed could deny coverage.
In the first instance, the company was ordered to authorize and pay for the examination, in addition to paying compensation for pain and suffering. Both parties appealed.
Upon analyzing the records, Judge Marco Aurelio Ferenzini pointed out that, although the exams were not listed in the list of mandatory procedures of the ANS, the fact in itself does not remove the defendant’s responsibility to pay for them. “The referred list cannot be considered exhaustive and there is no express contractual exclusion for carrying out such exams”, he stated.
As for the patient’s request, the magistrate understood that R$ 2 thousand are sufficient to repair the moral damage suffered. With information from the press office of TJ-MG.