The health plan is obliged to pay for the treatment of a child with autism and pay R$10,000 to the family; understand | More health

The court in Bertioga, on the coast of São Paulo, ordered a health plan to pay for multidisciplinary treatment for a 5-year-old child with Autism Spectrum Disorder (ASD) and pay R$10,000 to the family for moral damages. The decision was made after the company provided only one treatment option in Santos (SP), which would take 5 hours to travel on public transport.

“It would be very difficult to take him, plus he would be super nervous and out of routine because of school”, said mother Edjane Bezerra de Medeiros, 27, who thought about giving up her son’s treatment, but was encouraged by other women facing the same battle fighting for their rights.

The son, Pedro Medeiros, was diagnosed with ASD at the end of 2022 by a neurologist, and the professional issued an urgent report to begin treatment. The mother told the g1 having taken him to the consultation after noticing that the child had speech delay and difficulty interacting socially.

With the diagnosis and medical order in hand, Edjane said she immediately activated the Ana Costa Saúde plan which, according to her, gave only one option. “The plan said that there would only be one clinic in Santos. There would be no other place, in other words, do it there or don’t do it anywhere.”

Distressed, she told the reporting team that she shared the situation on social media, when she said that she would give up treatment due to the difficulties and inconvenience her son would go through. The woman, however, changed her mind due to comments encouraging her to take legal action.

According to the family’s lawyer, Mario Bernardes, the clinic specializing in the treatment of children with ASD closest to the family’s home is in the neighboring city, in Guarujá (SP). But, because it is not accredited, the agreement is paying.

Even though it’s not in the city where they live, the journey doesn’t take even an hour. Now, funded by the health plan, Pedro undergoes treatment with a psychologist, educational psychologist, Occupational Therapist (OT) and speech therapist.

“The quality of life improved 100%. Pedro didn’t say anything, the most was ‘mama’ and ‘papa’. Now, he sings, plays a lot with other children and this is all after the therapies […]. If it depended on the plan, my son wouldn’t be talking today and wouldn’t be receiving treatment”, said Edjane.

The lawyer explained to the reporting team that the health plan appealed the decision, but, while the appeal is not analyzed, the company remains responsible for complying with the first instance determination: paying for the treatment and moral damages.

In the sentencing document, the judge of the 1st Civil Court of Bertioga, Thais Esteves, stated that the agreement’s allegation was that the ABA method (acronym in English for Applied Behavior Analysis), prescribed for Pedro, did not is listed on the National Health Agency (ANS).

The judge confirmed the allegation and said that it was a consumer relationship. “The contract […] guarantees the applicant [Pedro] hospital medical coverage for treatment of illnesses. Therefore, the treatment, which [o paciente] must be submitted, must have the necessary coverage”, he pointed out in the decision.

In a note, the Ana Costa Saúde plan stated that the patient undergoes treatment at the Matheus Alvares Neurological Rehabilitation Center, in Guarujá, with a workload of 10 hours per week.

The company, however, did not respond to the reporting team’s questions about the reason for refusing to pay for the treatment before the legal action.

According to the lawyer specializing in Health Law, Gabriela Guerra, the law determines that if there is no qualified professional for the patient’s needs in the accredited network, the health plan is obliged to pay for the treatment in the city where the person lives.

Since 2022, according to the expert, the Health Plans Regulatory Agency has determined that therapy for children with autism must take place unlimitedly, that is, without limits on the number of sessions.

“What the doctor prescribes, justifying the need for that patient, can be achieved in court”, stated the lawyer.

Gabriela added that the only service that the Court does not authorize the health plan to pay for is Therapeutic Monitoring (AT), but there are still exceptions. The patient must prove that they need it for neuromotor development and not for educational purposes.