Paulo Antônio de Araújo Barbosa, 75, fondly remembers the health plan he had when he was responsible for the production department of the former CEG (Companhia Distribuidora de Gás do Rio de Janeiro), today Naturgy.
“I paid a symbolic amount for a wonderful plan, which took care of me, my wife, my three children, my father and my mother”, says the chemical engineer, who left CEG in 2000, aged 53, after obtaining a special pension. for insalubrity and danger.
Now he is desolate: it is the second time, in two years, that he is forced to change his health plan due to high contractual readjustments. “There was Unimed Rio, Delta category, offered by Aprogas [Associação dos Profissionais da Companhia Distribuidora de Gás do Rio de Janeiro]but they showed an absurd increase, of more than 70%”, he says. “The monthly fee for me and my wife would jump from R$ 3 thousand to R$ 5.2 thousand”, he says.
Trying to escape the “stab”, he decided to join, at the beginning of last year, another collective membership plan, also from Unimed Rio, but now in the lower Alpha category.
On March 7, however, the scare was big: he received a letter from the health plan administrator QV Benefits saying that the Unimed Rio – Alfa plan would be readjusted by 133.45%.
“From R$3,080, the value of the plan for the two of us would jump to R$7,200”, he says. “I panicked! Our gross income is in the range of R$ 9 thousand. If I pay the plan, there’s barely enough to eat”, says Barbosa, who will now join the MedSénior family plan, aimed at seniors, in an attempt to keep spending R$3,000 a month for him and his 73-year-old wife.
“I have no choice,” he says. “R$ 3 thousand is already very tight”, says the retiree from Rio de Janeiro, who has been a marathon runner before facing bowel cancer, five years ago. “But I’ve been cured since 2019, I just do routine exams. You can’t put the old cancer in this loss ratio account”.
The case of Barbosa illustrates what happens in corporate and collective health plans by membership, whose readjustments are not regulated by the ANS (National Agency for Supplementary Health). In most cases, operators practice increases well above inflation. The government agency regulates the price of individual and family health plans only.
The letter from QV Benefits, received by Barbosa, to which the sheet had access, says that the contract with the Unimed Rio plan “is readjusted annually, in April, according to the contractual loss ratio, calculated and calculated based on the relationship between income and assistance costs of your policy”.
The document also says that, “considering the loss ratio calculated in your policy, the readjustment percentage will be 133.45%, the minimum to adjust the financial balance of the collective agreement by adhesion”.
Health plans do not explain the increase even to the courts, says lawyer
For the lawyer specialized in the health area Rafael Robba, a partner at Vilhena Silva Advogados, this relationship between income and expenses is not transparent.
“If you try to obtain this information in detail from the operator, which was the revenue and which was the expense that justifies a rise of this size, you will hardly get it. Sometimes not even in court”, says he, whose office serves companies that are having to deal with increases of 26% to 45% in the last year. Among the cases are SulAmérica (which has just been purchased by Rede D’or) and Bradesco Saúde.
“When the beneficiary files an action to question the readjustment, Justice usually requires that the plan clearly demonstrates the data and criteria used to arrive at this index”, says Robba.
“But in most cases, the operators do not demonstrate. Not even when the judge determines the performance of expertise”, says the expert. “Because of this, the Justice understands that the adjustment is abusive and reviews the value”, he says.
Lenira Santos, administrative director of Alphageos, which specializes in engineering services, is outraged. She has had a contract with SulAmérica for five years, which serves the company’s approximately 300 employees and their dependents.
“Every year, they try to impose very high readjustments on us, around 50%, but we manage to renegotiate them up to around 15%, 17%, as long as the contract is linked to a two-year permanence in the plan”, she says. .
In the last adjustment, in October, a new increase far above inflation: 26%. “On the advice of the lawyers, we decided not to renew and question the increase in Justice”, she says, who complains about the lack of access to information that justifies the increase in claims.
“If I pay the car insurance and an accident occurs, I can activate the insurance without problems”, says Lenira. “Why can’t I do the same with health insurance? Why do I need to be penalized for what I paid to use?” she asks.
Rafael Robba explains that there are two readjustments for health plans: the annual readjustment, applied every year in the contract anniversary month and the same for all beneficiaries, and the readjustment by age group, applied according to the user’s age change.
“Today, the last adjustment allowed by age group is at 59 years old”, he says. “After 60 years, only the annual adjustment”, she says. In this case, the readjustment must, necessarily, be foreseen in the contract: in which age group changes the plan will be increased and in what percentage.
“Theoretically, the company can change providers – but if the company has elderly or sick dependents, it is more difficult to close with a new plan”, says Robba, who criticizes the ANS for not exercising oversight on readjustments by claims. “The operator ends up being free to apply the index it wants”.
Unimed Rio, which indicated the increase of 133.45% to Paulo Antônio de Araújo Barbosa, stated in a note that “the defined percentage aims to balance the gap between revenue and expense over the last twelve months of use”.
When contacted, Bradesco Saúde and SulAmérica decided to respond through FenaSaúde, an association that represents 15 groups of operators and private insurance. THE sheet questioned why the readjustment of corporate and collective plans by membership is above inflation (in 2021, the IPCA was 10.06%) and the lack of transparency involving information on claims.
Through its press office, FenaSaúde highlighted the cost pressure caused by the “highest general inflation in five years”, the resumption of elective procedures and the high accident rate in the first quarter of this year, of 82% – according to the association , the rate measures the degree of commitment of revenues to the payment of expenses.
And he said increases of 133% are the exception, not the rule. “According to ANS data, in 2021 the collective plans had an average adjustment of 5.55%”, he informed. According to the association, consumers can use the operator’s service channels in search of clarification on the readjustment rates.
The ANS, also through its press office, said that it “regulates both individual/family and collective plans (business and membership)”. In the latter, the adjustment is defined in a contract “and established based on the commercial relationship between the contracting company and the operator, in which there is room for negotiation between the parties.”
According to the ANS, operators are required to offer “the contracting legal entity of the readjustment calculation memory and methodology used at least 30 days in advance of the scheduled date for the readjustment application”.