Insurers must cover treatment for children with autism

The List of Health Procedures and Events of the National Supplementary Health Agency (ANS) is minimal and mandatory and does not exclude coverage of other necessary treatments.

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With this understanding, the 6th Civil Court of São Paulo sentenced the health plan operator Amil to cover ABA therapy for a five-year-old child with autism, in addition to indemnifying her in R$ 5 thousand.

According to the decision, the multidisciplinary treatment must be done in a clinic of the accredited network of Amil. If none of them is competent to apply the approach, the treatment must be done in a private clinic and paid for by the health plan, regardless of the distance to the boy’s house.

Therapy by the ABA method in a natural environment (home or school) was indicated to the child by medical prescription. Treatment should include at least speech therapy, psychology and occupational therapy. Amil claimed that coverage would not be mandatory, as it is not provided for by the ANS list.

“Once the illness is covered by the health insurance contract, the insurer cannot choose the treatment that best suits it from a financial point of view, and must cover all the procedures necessary for the dignified treatment of the insured”, said judge Fabio Coimbra. Junqueira.

The magistrate highlighted that the treatment indicated “is undeniably
superior to conventional treatments”. In other words, it would not be a simple option between two equally efficient treatments.

Junqueira also recalled that autism spectrum disorder compromises the child’s standard development and causes concerns and anguish for her and her family. Thus, the denial of coverage would not be a “mere contractual breach”, but also the cause of a “global neurodevelopmental delay”. Therefore, she stipulated the indemnity.

In the case, the attorney Gustavo de Melo Sinzingerfrom Sinzinger Advocacia.

Click here to read the decision
Process 1137403-53.2021.8.26.0100

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