Health plans: new rules for notice of exclusion of beneficiaries come into force in September

A National Supplementary Health Agency (ANS) extended the validity period of Normative Resolution (RN) 593/2023, which establishes new rules to deal with issues of default in health insurance, including exclusion, suspension or termination of contract. The new date for starting the resolution was set for September 1, 2024.

In a statement this Monday, the 22nd, ANS stated that it decided to extend the deadline to develop informative material that clarifies in a simple and quick way the doubts that may arise with the changes introduced by the resolution.

Furthermore, the extension aims to provide additional time for healthcare operators to adapt to the new guidelines.

With the new guidelines in place, mobile phone operators health insurance will be responsible for contacting the beneficiary to discuss the default until the 50th day of late payment, before considering any exclusion, suspension or unilateral termination of the contract.

It is important to highlight that changes to the contract as a result of default will only be valid after the 50th day of delay if the operator grants a period of ten days for the pending payment to be made, counting from the moment the beneficiary is contacted. It is worth noting that delays in monthly payments already paid will not be counted as default for the purposes of termination, suspension or exclusion of the contract.

Furthermore, the resolution establishes that the exclusion of the beneficiary or the suspension and unilateral termination of the contract due to default can only happen after at least two unpaid monthly installments, consecutive or not, within a period of 12 months. And it is up to the operator to clearly prove the notification about the situation of defaultshowing the date of notification to the consumer.

When RN 593 comes into force, new ways of dealing with defaults with health plan users will be allowed, such as sending emails, sending text messages via messaging apps (such as WhatsApp) and making phone calls.

But be careful: SMS or app notifications will only be accepted if the recipient responds, confirming that they received the message.

Communication by letter or by representatives of the operator, with a signed proof of delivery, will also continue to be valid. RN also says that notifications must provide information such as which installments are pending, how many days of delay have already occurred, when the debt must be paid and how the user can regularize the contract, in addition to providing the operator’s contact details to answer questions.

If the operator is unable to speak to the user about the lack of payment, cancellation of the contract is only permitted after 10 days since the last contact attempt, as long as it proves that it tried to notify the beneficiary by all means permitted by the resolution.

RN 593 applies to contracts signed after January 1, 1999 and to those that were adjusted following Law 9,656/1998, which specifically deals with private health plans. If the contract was made before the resolution took effect, changes will be allowed to include the new guidelines.