Health plans and obstacles to patient well-being

In the context of the right to health in Brazil, private health plans are regulated by the National Supplementary Health Agency (ANS), which establishes standards and guidelines to guarantee healthcare coverage for consumers. However, there are several obstacles that can affect access to health and the well-being of users of these plans. There are countless cases every year that often end up in the courts of law.

One of the main barriers is the coverage limitations imposed by some health plans. Although the ANS defines a minimum list of procedures and services that must be covered, plans often establish clauses that restrict access to treatments, medications and procedures that are outside this list or that are considered experimental. And this causes serious situations for users’ daily lives, as the patient needs specific treatment that is not covered by the plan, generating high private costs or the need to resort to the Unified Health System (SUS).

Another common problem is related to waiting periods, which are periods stipulated in contracts during which the beneficiary is not entitled to certain coverage. These periods can make immediate access to essential health services difficult, especially in cases of urgency or emergency, despite there being regulations that limit needs in such situations.

Furthermore, the high value and the practice of monthly fee adjustments, often considered abusive, especially for the elderly or in collective corporate plans, can compromise the consumer’s financial ability to maintain the health plan, directly affecting their well-being.

Administrative and bureaucratic issues also represent barriers, such as the requirement for prior authorizations for procedures and the delay in releasing these authorizations, which can delay treatments and affect the patient’s health.

In cases of denial of coverage or abusive practices on the part of health plans, consumers can seek help from the Judiciary to guarantee their rights.

Brazilian jurisprudence has been sensitive to the demands of health plan users, often determining the coverage of treatments and medicines not included in the ANS list or considered experimental, based on the principle of human dignity and the right to health.

Patients need to be aware of their rights to face these various obstacles imposed by health plans. And, although judicialization is one of the only ways to overcome these blockages, the effort must be continuous to improve accessibility, quality and balance in the services provided and contracted in health plans to minimize the impacts on health problems in Brazil.