Health plan is condemned for denying coverage

Health plan is condemned for denying coverage
Health plan is condemned for denying coverage
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The Court of Justice of the Federal District and Territories (TJDFT) unanimously upheld the conviction of a health plan to compensate a patient for denial of coverage during the contract’s grace period. The decision set the amount at R$23,000 for material damages and R$3,000 for moral damages.

According to the process, in January 2022, the author passed out while driving in Recife (PE) and, upon arriving in Brasília, underwent several tests. Doctors recommended urgent surgery and complementary treatment with radiotherapy and chemotherapy, due to the cancer diagnosis.

Despite the urgency, the patient claims that the health plan refused to cover the costs of his treatment, which meant that he had to cover the expenses with the support of family and friends.

In the appeal, the health plan argues that the grace period provided for in the contract must be respected, since the urgency/emergency of the surgical procedure has not been proven. He maintains that there is no moral damage to be compensated and that, if this understanding is maintained, he requests a reduction in the compensation amount.

In the decision, the board highlights that the urgency was proven not only by the exams and medical reports, which inform the diagnosis of malignant neoplasm of the brain, but also by the diagnosis and reports that confirm the need for urgent treatment. Thus, for the Appeal Panel “the presence of the presuppositions of urgency and emergency remains evident”.

In this sense, the reporting judge mentions Law 9,656/98, which establishes the obligation to cover care in cases of urgency and emergency, “without considering the waiting periods applicable to the health plan”. Therefore, “given that the defendants’ refusal was unjustified and not supported by the legal system, it is imperative that they fully assume the plaintiff’s costs[…]”, concluded the judge.

The article is in Portuguese

Brazil

Tags: Health plan condemned denying coverage

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