Health plan without obstetric coverage must pay for urgent delivery

Coverage of care in case of emergency delivery is mandatory, even if the contracted health plan has segmentation without obstetric coverage.

Law on Health Plans provides for an obligation to pay for urgent care

reproduction

The 3rd Panel of the Superior Court of Justice applied this understanding by rejecting the special appeal filed by a health plan against a conviction to pay compensation for moral damages for the refusal to attend to a pregnant woman about to give birth.

In this case, the woman went to an agreed hospital and, in labor, was informed that she would need emergency hospitalization because the baby was in fetal distress. However, the health plan would not cover the procedure.

The hospital did not attend to the pregnant woman and advised her to run out of time for some other unit. With that, the woman requested an ambulance and was taken to a public hospital, where the emergency situation was confirmed. Delivery was performed and the newborn needed to be resuscitated.

Both the health plan and the hospital were condemned by the ordinary instances to indemnify the woman in a final amount arbitrated at R$ 10 thousand each.

To the STJ, the health plan argued that it cannot be ordered to cover childbirth because the contract signed with the beneficiary was for hospital segmentation without obstetric coverage, which is fully permitted by the Health Plans Law (Law 9,656/1998).

Rapporteur, Minister Nancy Andrighi pointed out that, in fact, the law and the rules of the National Supplementary Health Agency (ANS) — in Normative Resolution 25/2012 — allow the segmentation of services in the sale of health plans.

On the other hand, article 35-C, item II, indicates that health plans are obliged to cover emergency care, including complications in the gestational process.

Minister Nancy’s vote cites the rules of the Supplementary Health Council, the ANS and the STJ’s own case law, which indicates that urgent and emergency coverage is not limited to what was spent only in the first 12 hours of treatment.

“Therefore, the fact that the beneficiary’s health plan is of hospital segmentation without obstetrics does not change the duty to cover emergency care resulting from complications in the gestational process, since, as seen, it is a case of mandatory coverage” , she said.

The vote in the 3rd Panel was unanimous, according to the position of Minister Nancy Andrighi. She was accompanied by ministers Ricardo Villas Bôas Cueva, Marco Aurélio Bellizze and Moura Ribeiro. Justice Paulo de Tarso Sanseverino did not participate, justifiably.

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