The health plan Sul América Seguro de Saúde was ordered to indemnify a patient for denying coverage for hospitalization and emergency cesarean section. The judge of the 22nd Civil Court of Brasília concluded that there was a failure to provide the service and that the dignity of the user was affected.
According to the lawsuit, the patient was 38 weeks and three days pregnant when she was diagnosed with gestational hypertension, known as preeclampsia. The doctor would then have requested emergency admission so that the cesarean section could be performed. The health plan, however, denied coverage on the grounds of contractual grace. Delivery was performed after court order.
The woman asked for compensation for what happened. The health plan argued that the denial of coverage was legitimate and that there were no moral damages.
In the decision, the judge pointed out that there is no basis for the health plan to deny service. She pointed out that, for urgent and emergency situations, the minimum grace period is 24 hours.
In the case of the contract signed between the plaintiff and the health plan, there was a clause setting the grace period of 300 days for carrying out a full-term delivery. This clause, according to the judge, is not applicable, since “it would be in clear disagreement with the provisions of the aforementioned Law No. 9,656/98”.
“The recommended treatment, in the case of the case, is urgent, and, obviously, has mandatory coverage. (…) Even in cases where the provider inserts, in the adhesion contract, a contractual clause of grace and exclusion of any coverage (even in cases of emergency), the nullity of the stipulation must be recognized, for offense to the fundamental principles of the consumerist system and in the face of the threat of emptying the object of the health care contract”, he recorded.
Thus, Sul América was ordered to pay R$ 5 thousand for moral damages. However, the sentence is appealable.
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