Paulo Duarte wants health plans to justify denial of coverage – Politics

The bill by state deputy Paulo Duarte (PSB) began to be processed in the Legislative Assembly, which aims to oblige health plan operators or private health care insurance to present information and documents to the consumer regarding the denial of partial or total coverage of examinations, medical, surgical or diagnostic procedures, as well as treatment and hospitalization. The text will be analyzed by the CCJR (Constitution, Justice and Writing Committee).

If approved and sanctioned, the law determines that in the event of denial of coverage, whether total or partial, the health plan or insurance operator must provide the consumer, regardless of request, with proof stating the reason for the denial in a clear manner, without vague expressions, abbreviations or codes.

“As long as private plan and insurance operators do not meet the necessary conditions to adequately provide the relevant health service, actions in the administrative and judicial spheres will continue to be fundamental to adapt health plan contracts”, he explained. the parliamentarian.

The document must also include the client’s name, health plan contract number, the reason or corporate name of the operator or insurer, the national legal entity registration number (CNPJ), address and a copy of the application form. to authorize coverage.

Furthermore, upon request, the private hospital must provide the consumer, at the place of medical care, with a written statement containing the denial of coverage, date and time of the denial. The health service user must also receive a report from the responsible doctor, attesting to the need for the intervention and, if applicable, its urgency.

“Understanding health plan contracts as instruments supported by Consumer Law, the conduct of loyalty, information, honesty, cooperation and good faith must also be more than visible, guaranteeing contractual balance between the parties”, he concluded.

In the event of non-compliance with the law, the operator will suffer administrative sanctions, as determined by the Consumer Code. However, there is a caveat. In cases of assistance involving urgent or emergency procedures, the imposition of a fine at a level lower than 100 UFERMS (State Fiscal Unit and Reference of Mato Grosso do Sul) will not be permitted. This month, the value is equivalent to R$4,842.

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