Supplementary health accounts for 130,000 lawsuits annually

In the period between 2015 and 2021, an average of 400,000 new processes related to health in the country were registered per year. Of these, 130 thousand were related to health plans and insurance. The data were presented by counselor Richard Pae Kim at the opening of the seminar “Judicialization of Supplementary Health”, promoted by the National Council of Justice in partnership with the National Supplementary Health Agency (ANS) on Wednesday (27/4).

reproductionSupplementary health accounts for 130,000 lawsuits annually

According to the counselor, who is part of the National Forum of the Judiciary for Health (Fonajus), in 2020 alone, there were 149,047 claims against health plans and insurance. Pae Kim pointed out that, in about 80% of the actions proposed against the Unified Health System, injunctions are granted, a number that drops to 70.7% when it comes to private health.

“As for the result of these demands, 77.7% of the actions are upheld against public health bodies, while 10% are considered unfounded and 12.1%, partially valid,” he said.

The counselor detailed that, in supplementary health, the data show that 42.9% of the cases are judged valid, 36.8%, unfounded and 20.3%, partially valid. He also emphasized that the Judiciary, despite the increasing number of actions, whether in the area of ​​public or private health, has been able to decide within reasonable deadlines.

“In parallel with all the actions that we are implementing to overcome the judicialization of the sector, we have to continue our investments in mediation and conciliation to avoid the entry of new lawsuits, working in the pre-procedural phase”, explained Pae Kim.

In this sense, he highlighted actions developed by Fonajus, such as the expansion of the National Bank of Opinions (e-NatJus) for cases involving supplementary health and the cooperation signed between the CNJ and the ANS last year.

According to him, these measures promote knowledge and the exchange of information related to health between the public administration and health plans, which will have elements to make adjustments to their respective administrative acts.

The counselor also stated that “the right to a quality life and the right to health as a consequence are the most fundamental of all rights insofar as they constitute prerequisites for the exercise of all other rights, especially fundamental rights”.

Legal certainty
When dealing with the subject, counselor Mauro Martins defended strict respect for what is established in contracts between users and supplementary health companies. “What has been established between the parties must be complied with. And there is no way to grant benefits that are not agreed because, if we do otherwise, we can compromise legal certainty and cause repercussions that can affect the community,” he said.

Strict respect for what is established in contracts between users and supplementary health companies was defended by Martins during an event aimed at improving technical knowledge about the sector, discussing and seeking solutions to the problem of increasing judicialization in the segment.

Martins highlighted that health plan contracts have an actuarial basis and pointed out that, when there is an imbalance, there are repercussions at the collective level. “When the judge decides an individual case, of course he is solving a specific case, but he needs to keep in mind the repercussion of his decision as a whole.”

He pointed out that the issue challenges the Brazilian judiciary on a daily basis, which is why he believes that solutions must be built from exchange, information exchange and building bridges between the institutions involved in the issue. According to Martins, in many situations, the magistrate is obliged to grant an injunction that may be based on wrong premises. “Pressed by the need of a citizen whose life is at risk and resorting to justice in search of an injunction, the judge has no alternative but to grant that injunction.”

Also present at the event, which was attended by more than a thousand people, counselor Mário Maia spoke about the relevance of the work developed by the CNJ in the area and, as the father of an autistic child, highlighted that many services that should be offered to these people are denied or neglected by the state. “It’s not possible to limit science to a list.”

Consequences
President of the National Supplementary Health Agency (ANS) and member of the Executive Committee of Fonajus, Paulo Roberto Vanderlei Rebello Filho highlighted the importance of debates on supplementary health and recalled that one in four Brazilians has a health plan. “As the counselor rightly mentioned, when addressing the consequentialism of decisions that are adopted by the Judiciary, it is important to understand the effects and consequences of these acts.”

According to Rebello Filho, the seminar provides the right moment to disseminate information and the work developed by the agency. “ANS is looking for the Judiciary and consumer protection bodies to establish agreements and cooperation to promote the exchange of knowledge and, consequently, gains for the whole society”, he said.

Lawyer Luiz Felipe Conde, representative of the Federal Council of the Brazilian Bar Association (OAB), pointed out the importance of the participation of lawyers in the debate involving supplementary health. “The lawyer participates in this relationship involving health, since he is present representing society, as in this meeting, as he represents the service consumer citizen and also the service providers”, he argued. With information from the CNJ Press Office.

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