“I can’t afford it,” says the mother of a paralyzed child about the STJ’s decision to change her health plan

Jamille Adler’s son has cerebral palsy and now needs procedures that he is not forced to pay for.

Jamille Adler’s son has cerebral palsy and now needs procedures that he is not forced to pay for. (Personal archive)

SÃO LUÍS – Physiotherapist Jamille Adler, who lives in São Luís, treats breast cancer and is the mother of a six-year-old child with cerebral palsy. Like many patients in Brazil, he was shocked and concerned by the decision of the High Court of Justice (STJ) to exempt the Health Plan from paying for treatments or medicines not listed by the National Health Agency (ANS).

Jamill explains how the decision affects her and her son’s lives from now on. “The doctor prescribes a specific treatment that is not on the ANS list, and the plan can be denied, but if I go to court, the judge can comply, as he usually does. What will happen is that the judge will not have that power, because the role is not exemplary, it is exhaustive, ”he says.

Lawyer Gabriel Costa, who has a master’s degree in Constitutional Law, has revealed that the consumer who is most affected by the STJ’s decision is the consumer. “The conclusion is that the weakest part of the consumer will not be able to request more procedures, medicines, oral chemotherapy, radiotherapy and surgery that are not included in this list. I understand that this is a very basic role. Only the one who is harmed, the most vulnerable, is the consumer. It remains to be seen whether the STJ will maintain its understanding of the resources that may arise or whether this understanding will be established in jurisprudence, ”the lawyer explained.

He believes the agreements could be much more legitimate to deny the necessary treatment, as they will be accepted in the decision. But consumers who feel affected are advised to seek a lawyer for specialized guidance.

“If there is no therapeutic alternative on the ANS list, the judiciary may impose the doctor’s recommended coverage if that treatment has proven effective and the ANS has not expressly ruled it out before.
Therefore, it is up to the consumer to find a specialist lawyer to sue for the cost of his or her treatment of justice, so as not to violate his or her constitutional right to life, ”added lawyer Gabriel Costa.

Read more:

STJ: Plans are not required to cover behavior outside of the ANS list

Individual health plans have a historic rise

In practice, physiotherapist Jamille will have to pay an extra amount for his son’s treatment, in addition to the fee he already pays monthly from the health plan. The result is an explosion in spending. “Today my son is being treated for about 7 to 10 thousand reais a month, which I was forced to pay before the plans, and now that I have no conditions to pay for that, he will be without any treatment, without any treatment. coverage. In my case, this is roughly the case with cancer. There are no tests on the list, no treatments, ”Jamill said.

Decision

The STJ ruled yesterday (8) that health plan operators should not cover medical procedures that are not provided for in the ANS list. There is an appeal against the decision.

Section Two of the STJ understood that the list of procedures specified by the agency is detailed, meaning that users are not entitled to any examinations and treatments that are off the list.

With 3 against 3, Minister Luis Felipe Salomão prevailed over the understanding of the reporter, whose vote he had given in previous meetings.

In defining the list as accurate, the minister understood that there would be an imbalance in health plan contracts if some users could get in court the right to coverage that others do not. This would affect the economic balance of the supplementary health system and increase the costs for all users, according to the minister.

The list of mandatory ANS procedures and treatments was created in 1998 to establish a minimum coverage that health plans could not deny. The list has since been updated to include new technologies and advances.

Since then, it has become commonplace for health plan users to sue the right of operators to pay for procedures or treatments that are not yet on the ANS list.

Historical growth in health insurance

The National Agency for Complementary Health (ANS) last month approved a maximum annual readjustment index for individual and family health plans. The increase can be up to 15.5%. The decision was taken by a vote of four against the council.

This is the largest annual adjustment ever approved by the agency in 2000. Health plan operators may apply the index to monthly fees charged between May 2022 and April 2023. But values ​​can only be updated. from the anniversary of each contract. If the month of the contract is May, the adjustment may be charged retroactively.

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