What changes with a decision that limits health plan coverage – National

The STJ reached a decision after the judgment of embargoes of divergence in two special appeals involving a medical cooperative in Campinas (SP). In them, the group challenged the obligation to cover the treatment of a child with autism spectrum disorder. The procedure in question is not described in the ANS list.

The decision was celebrated by the entities that represent the operators. The National Federation of Supplementary Health (Fenasade) indicated that the STJ’s decision on the coverage of health plans was “correct”, and that the agreement would benefit 49 million users. “The ratification that the List of Procedures and Events in Health, from ANS, is exhaustive, guarantees, in the first place, patient safety, in addition to legal security and the sustainability of health plans”, says the note from the entity.

“The STJ’s decision recognizes that institutional mechanisms for updating the list are the best way to introduce new technologies into the system. Today, Brazil has one of the fastest technology incorporation processes in the world, which can be completed in four months . All this regulatory framework, preserved by the decision of the STJ, guarantees the sustainability of the system”, evaluates Fensade.

Professor of health economics at the University of Rio Grande do Sul (URGS), Giacomo Balbinotto highlights that, although it seems contradictory, the exhaustive role allows health plans to have greater predictability and the sector should benefit from the decision. “The decision guarantees legal security to the plans, which, from an economic point of view, contributes to the sustainability of the portfolios. In this respect, it is a very welcome decision”, he says.

Gustavo Kloh, professor at FGV Direito Rio, said that admitting an indeterminate list of procedures would end up harming users who did not demand special care. “The plan could be excessively expensive for everyone. With the taxing list, it is possible to make a more efficient calculation (of the monthly fees)”, he evaluates.

Entities linked to users, such as family members of people with autism spectrum or rare diseases, lamented the defeat. “Diseases cannot be chosen, much less treatment. So, if someone has had a health plan for 20 years and is surprised by some rare disease, for example, the health plan cannot provide only if it is obliged. , which the ANS should not be protecting”, said Ren Patriota, executive coordinator of the Association for the Defense of Insurance, Plans and Health System Users (Aduseps).