STJ decides to keep the list of mandatory coverages of the ANS — Portuguese (Brazil)

This Wednesday, 06/08, the Second Section of the Superior Court of Justice (STJ) decided, by 6×3 votes, to maintain the exhaustive nature of the list of mandatory health plans coverage, defined and periodically updated by the National Supplementary Health Agency. (ANS).

The list of health procedures and events is the list of consultations, exams, therapies and surgeries that constitute mandatory coverage for regulated health plans (contracted after 01/2/1999 or adapted to Law 9,656/98). This list has more than 3,000 items that cover all diseases listed in the World Health Organization (WHO) International Statistical Classification of Diseases and Related Health Problems.

The result of the vote means that six of the nine ministers of the Second Section understood that the list of procedures does not only contain examples to be consulted by operators, but the list of mandatory coverage that must be guaranteed by law. Click here for information on the STJ’s decision..

The elaboration of the List of Procedures and Events in Health is one of the main achievements enshrined in law in the health insurance market. It is important to remember that before Law 9,656/1998 there was no list of mandatory coverage covering care for all diseases listed by the WHO, nor was there a regulatory agency with the specific role of monitoring its faithful compliance.

The exhaustive nature of the list of mandatory ANS coverage means that the health procedures and events on this list cannot be denied by the operators, under penalty of having the marketing of plans suspended or being fined.

With today’s decision, the STJ provides for some exceptions that must be considered by operators, having been defined that if there is no therapeutic substitute or if the list of procedures is exhausted, the treatment indicated by the doctor may be covered, provided that the following requirements are met:

I – the incorporation of the procedure to the Complementary Health List has not been expressly rejected by the ANS;

II – there is proof of the effectiveness of the treatment in the light of evidence-based medicine;

III – there are recommendations from renowned national technical bodies, such as: conitec, NatJus and foreigners;

IV – whenever possible, inter-institutional dialogue between the Magistrate is carried out with entities or people with technical expertise in the health area, included with the mission of updating the List of Procedures and Events in Supplementary Health, without shifting the competence to judge the case to Federal Court before the passive ad causa illegitimacy of the ANS.

It is important to emphasize that the Agency has been systematically improving the process of updating the list, making it more agile and accessible, as well as ensuring extensive social participation and prioritizing the safety of the procedures and health events incorporated, based on the most modern in HTA – assessment of health technologies, focusing on evidence-based health.

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She's our PC girl, so anything is up to her. She is also responsible for the videos of Play Crazy Game, as well as giving a leg in the news.

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