Legal Tips: How prepaid companies should accept (and charge) users with “pre-existing conditions”

“They don’t take me to prepaid because they say I have a pre-existing condition.”: This phrase is repeated in questions asked to lawyers who are dedicated to health law, such as “They want to charge me hundreds of thousands of pesos because they say I already have a disease” or “They Statements like “Cancelled Enrollment” are repeated because prepaid insurance guarantees that I did not report a pre-existing condition when completing my health affidavit. All of these claims share a common point: the same logic. exclude someone from medical coverage For any alleged illness which the Member may have suffered before contracting the Prepaid Plan. Who determines what is a “pre-existing disease” or “pre-existence”? How much can be charged for a pre-existing condition? Can a prepaid pharmaceutical company refuse to register a person with a disease with its health system?

First of all, it is necessary to take into account that prepaid drug companies are governed by Law 26,682 and are contracts between one of these companies and the customer or user, This is a deal like no other, because what is at stake in these agreements is the health of one or more people. In the same sense, the rules protecting consumers govern (Law 24,240).

Law 26,682, in its Article 10, establishes that “Pre-existing diseases can only be established on the basis of the user’s sworn statement and cannot be a criterion for the rejection of users’ entry”, so that Even in case of a person suffering from any pre-existing medical condition, the prepaid medicine company cannot deny their subscription., Does this mean that health companies have the power to set any price for these users’ income? No, the same Article 10 establishes that “the enforcement authority shall authorize reasonably fair differential values ​​for the admission of users who have pre-existing diseases, as established by the regulations.”

This final guidance prevents prepaid drug companies – who obviously want to take on users who do not use their services, i.e., add “healthy” customers to their portfolio – from accepting a user with a disease. By fixing any amount for it. Decree 1993/2011, which regulated Law 26,682, clarifies that Pre-existing conditions can be temporary, long-term, or costly., For this standard, pre-existing conditions of a temporary nature are those in which there is predictable treatment with medical discharge over a longitudinal period of time, while “conditions of a chronic nature are those in which, with the current scientific level, there is neither predictable clinical nor “There is growth and no permanent discharge. The timing can be determined.” Treatment.”

Finally, “those with high cost and low incidence are those in which treatment puts the parties involved at economic risk.” In such cases, The Superintendent of Health Services (SSSALUD) will authorize differential quota values ​​for pre-existing conditions, whether these are temporary, long-term and/or high cost, as well as the length of the payment period for the differential fee.” Prepaid drug companies that wish to collect this differential value must submit a request to the Superintendent, and submit it themselves. Cannot be determined with your audit criteria.

At the end of November 2023, based on resolution 2400/2023, SSSALUD was established, some new guidelines A sworn declaration of an individual’s health is the only means by which it can be assumed that a pre-existing condition exists. The regulations of Law 26,682 establish that for a prepaid company to cancel a user, it must be able to prove that the subscriber did not act in good faith when completing the sworn declaration.

Proving that a person did not “act in good faith” represents many difficulties for prepaid companies., because according to this rule, failing to record a disease when registering will not mean that there was bad faith. In this sense, the aforementioned Resolution 2400/2023 reversed a norm that would be more favorable to companies, since it stipulated The institution may cancel the membership if it considers that there was no good faith, if the user “failed to report a pre-existing disease or condition requiring membership in an affidavit” or “knew of the pre-existing disease or condition.” Although this writing may shed light on some aspects, won’t stop bringing controversy That, just like nowUltimately resolved in courts.