Health Plans: Understand how STJ’s decisions can change the service

After undergoing the biggest readjustment in history, consumers of health plans may suffer a new blow this week. O High Court of Justice (STJ) will resume this Wednesday (7) the ruling on operator service, which currently provides service to about 50 million users.

The debate revolves around two different paths: whether companies should only provide the procedures and medicines on the National Supplemental Health Agency (ANS) list, or whether this ANS list is about the list of minimum services to be paid for under contract.

The decision is worrying, especially for patients with serious illnesses, such as cancer, who can now go to court to ensure comprehensive treatment, whether or not they are on the ANS list.

Judgment 1 is leveled. Only two ministers have voted so far: Luis Felipe Salomão has argued that the ANS list is accurate. That is, operators should only provide the client with the procedures, tests, and medications listed in the agency’s list.

On the other hand, Minister Nancy Andrighi disagrees with her colleague. In his view, companies engage in abusive behavior when they refuse support outside the role of the regulatory body.

O TEMPO’s report heard two experts on the subject, and they also disagree at the trial.

On the one hand, Marina Paulelli, a health program attorney at the Brazilian Institute for Consumer Protection (Idec), believes that operators have a duty to provide services beyond the role set by the ANS.

“This is the minimum parameter that must be guaranteed by operators for treatment, testing and medicines. This means that when a consumer contracts a health plan, they will have the security to have all of these technologies, whether or not they are on the ANS list. This has always been the case and there has never been a collapse of operators, ”said the expert.

Alessandro Acayaba de Toledo, president of the National Association of Benefit Administrators (Anab), disagrees with the lawyer. He argues his position with points related to the financial health of healthcare operators.

For example, he mentions the case of patients who do not accept generic drugs, which are usually cheaper, which would burden the company.

“When this happens, the ratio of the contract to the claim, the relationship between income and expenditure, does not match. As a result, this will lead to an increase in adaptation (individual plans), which is already large and inadequate. you will be using private plans, ”he says.

On the other hand, lawyer Marina Paulelli recalls that since the creation of Law 9,656 / 98, which regulates health plans, even in subsequent editions, Justice has always understood that the role of the ANS is a minimum service, not a maximum.

“It is very important for Justice to maintain its historical understanding because it provides security to the consumer. There is no risk of falling in the sector. According to the ANS itself, there has been growth over the last decade for the supplementary healthcare sector in terms of both expenditure and revenue. But, increasing the gap between them. It was more than just spending, ”he says.

Families prioritize plans

A survey released by the National Association of Benefit Administrators (Anab) shows that home ownership alone is a higher priority in family budgets than health insurance. After the pandemic, respondents put this type of service before education.

In numbers, 83% of SUS users understand that this type of procurement is necessary, the same percentage of operators’ customers who are “very afraid” of running out of contracts.

The average health expenditure for those with a plan is R $ 581.70 per month, according to the survey. Of those who do not have such a contract, 76% say they do not use the service for financial reasons, especially during the economic crisis, which has seen double-digit inflation over the last 12 months.

However, Anabe president Alessandro Acayaba de Toledo predicts an improvement in the sector. He recalled that the unemployment rate had fallen in recent months. The index is currently at 10.5% for the quarter between February and April.

“By employing more people, many get collective health plans. Even those who are informal or self-employed get the resources to hire the product, ”he says. The priority given by the family to the service is obvious: 47% guarantee that they would have to waive other expenses in order to be included in the monthly budget.

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