The Second Section of the High Court of Justice (STJ) has formed a majority this Wednesday (8) to establish health plan operators. they should not cover procedures not listed by the National Supplemental Health Agency (ANS)..
The decision includes coverage for testing, therapy, surgery, and drug supply, for example.
Six of the nine ministers who voted in the second section understood the call The ANS is a detailed list of procedures, meaning that the list includes not only examples, but all health plan coverage obligations.
Ministers Luis Felipe Salomão, Vilas Bôas Cueva, Raul Araújo, Isabel Gallotti, Marco Buzzi and Marco Aurélio Bellizze accepted this understanding.
Ministers Nancy Andrighi, Paulo de Tarso and Moura Ribeiro voted in the opposite direction. For these judges, the list should be “exemplary”, that is, represent the minimum coverage of the agreements.
- Understand, in four points, what the STJ has judged
Health plans: what can change with the coverage of the STJ ruling
The decision sets out exceptions
Understanding that the list is accurate must be modulated by STJ ministers accept some exceptions – for example, therapies specifically recommended by the Federal Medical Council (CFM), cancer treatments, and over-the-counter medications (used with a prescription for treatments not included in the package of this medication).
The thesis, which was considered correct by most ministers, was proposed by Minister Villas Boas Cuêva and put to the vote by Speaker Luis Felipe Salomão. In short, STJ’s understanding is this:
- The role of the ANS is generally overwhelming;
- the operator is not obliged to pay for a procedure if there is a similar option on the ANS list;
- it is possible to hire extended coverage or negotiate a contract change;
- if there is no therapeutic alternative, or after the procedures listed in the ANS have been exhausted, there may be exceptional treatment coverage indicated by your doctor or dentist.
In order for this exemption provided for in the fourth issue to apply, it is necessary to:
- the inclusion of the desired treatment in the ANS list has not been specifically ruled out;
- there is evidence of the effectiveness of treatment in the light of evidence-based medicine;
- there is a recommendation from nationally renowned technical organizations such as Conitec and Natijus, and from abroad;
- a dialogue between magistrates and specialists, including the committee responsible for updating the ANS list, is carried out, where possible, to ensure that such treatment is not included in the list of procedures.
The role is limited, experts say
Experts believe that the list of ANS procedures is very basic and does not include many important treatments – such as some types of oral chemotherapy and radiotherapy, drugs recently approved by Anvisa and surgeries performed with robotic techniques.
In addition, the ANS limits the number of sessions of certain therapies for people with autism and various types of disabilities. Many patients require more sessions than established with these therapies to achieve results, and so in the current model, they have the opportunity to gain acceptance of the health plan payment.
The trial in the STJ began in September last year, but two requests for views (more time to study the cases) suspended the deliberations of the ministers.
The dispute reached the Second Section after a disagreement between the two STJ groups. Now, the collegiate will determine what the limit of the duty of the operators is.
The STJ confirms its judgment on the list of health plan coverage
The case reporter, Minister Luis Felipe Salomão, defended that the ANS list is complete, but accepted the exceptions.
According to the Minister, the exact nature of the list is accepted in several countries and is a protection for the beneficiaries. This is because, in his view, the measure avoids excessive price increases in the plans.
The rapporteur’s vote proposes exceptional circumstances in which health care providers are required to pay for procedures not expressly provided for in the ANS.
These gaps include therapies with a specific recommendation from the Federal Medical Council (CFM) that have proven efficacy for specific treatments.
Cancer drugs and an “off-label” prescription (a drug used for unforeseen treatment in the package) may also be released.
Minister Nancy Andrighi disagreed with her colleague and considers the list to be exemplary in nature. For the Minister, the law protects the consumer.
“The list of procedures and events is an important guarantee for the consumer to guarantee the right to health, as an important tool to guide what operators have to offer. But it cannot replace the precise limitation of care coverage, excluding the detained consumer from the right to benefit from all the health procedures and events necessary for the treatment, ”he said.
For Nancy Andrighi, the list of ANS procedures “has only been exemplary, serving as an important reference for the operator and professionals and the treatments to be indicated. But never with a generic imposition of treatment that should be prescribed and covered by health plans. For certain diseases.”
The minister said the exemplary role he was facing was what he called a “predatory exploitation”.
“From the point of view of the Consumer Protection Code or the Civil Code, the exemplary role is to protect the consumer from the predatory economic exploitation of the service to which he refuses, denial of coverage without the aid of law, in order to meet the profit objective. operators ”.
The Minister argued that the evolution of medicine cannot be seen as a limitation of the duty assumed by the operators.