Health plan operator is condemned for refusing to provide medication

Refusal to provide medication, even in the face of evidence of need and effectiveness of treatment, results in a situation that goes beyond a simple breach of contract.

With this understanding, judge Eduardo Perez Oliveira, from the 2nd Court of Goiânia, decided that a health plan operator must provide the Tagrisso medication to a beneficiary and also pay R$6,000 for moral damages.

According to the decision, the woman is retired and does not have the financial means to pay for the treatment, which costs R$476,200. Despite the medicine being on the health plan’s list of mandatory coverage, the operator initially denied supply.

The company argued that the denial was due to the client’s failure to present essential documentation, which would also have occurred during the legal process.

Enough proof

The plaintiff then asked that the case be decided without the need for further evidence, while the defendant wanted more evidence. The judge understood that the existing evidence was sufficient for the trial.

The decision highlighted that the contract between the parties is governed by the Consumer Protection Code and that the medicine in question is listed by the National Supplementary Health Agency (ANS) as having mandatory coverage.

Furthermore, the judge considered that the operator’s initial refusal caused moral damage to the author, as she had to go to court to obtain the medicine, despite its proven need.

Thus, the sentence determined that the company must supply the medicine to the health plan client and also pay compensation for moral damages. The patient’s defense was carried out by the office Koop Alves Sociedade de Advogados.

Process 5365392-35.2023.8.09.0051