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

Man examines with stethoscope
(photo: Editorial de Ilustrao/CB)

The Superior Court of Justice (STJ) decided, yesterday (8/6), that the list of procedures listed by the National Supplementary Health Agency (ANS) for the coverage of health plans is exhaustive. This means that operators are required to cover only the items in the list. Experts defend the decision, arguing that it offers legal security to the plans, while user bodies say treatments are at risk.
In practice, the judgment needed to decide whether the list should be exhaustive, offering and limiting the list of mandatory procedures, or exemplary, serving as a minimum reference of services to be offered by health plans. By six votes to three, the 2nd Section of the STJ determined that the list is exhaustive, maintaining the mandatory service for the cases provided for in the ANS list, but with discretion, opening the possibility of analyzing the exceptions.
The list of ANS with more than 3,700 procedures had been considered exemplary by most court decisions on the subject. In this case, patients who were denied procedures that were not on the list could appeal to Justice to expand care. With the new understanding, the list contains all the obligation that the plans are obliged to pay, that is, what is not on the list does not need to be covered.
Although the decision of the STJ does not oblige the other instances of Justice to follow this understanding, the judgment serves as a guide in processes that deal with the subject. The ANS list comprises all the diseases listed in the International Statistical Classification of Diseases and Related Health Problems (ICD), of the World Health Organization (WHO).

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).

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