Patients live in uncertainty after deciding on STJ health plans




It was difficult for health plan users to get a treatment that is not on the list

Photo: Hush Naidoo Jade Photography / Unsplash

The decision of the High Court to exempt the Health Plan from covering procedures outside the list of the National Supplementary Agency for Health (ANS), such as examinations, therapies, surgeries and medicines, brought new concern to administrative coordinator Aguinaldo Vicente Junior. , A resident of São Paulo. She is already experiencing moments of anxiety as her health plan twice denied her son treatment with cannabidiol in the first days of her life when she was diagnosed with epilepsy. The plan said in fact that treatment with the medication was not on the ANS’s mandatory coverage list. He appealed to the Judiciary and, after the first refusal, obtained a court order ordering the health plan to supply cannabidiola.

Since then, she has been receiving medication from the insurance company on a regular basis to submit a medical report stating the need to continue treatment every six months. “I was impressed with the decision, as I believe that the STJ will rule in favor of those most in need. there is no change in the cases, ”he said.

Aguinaldo’s son, now 22 months old, had digestive bleeding a few days after his birth and was taken to the newborn ICU, where he developed severe bleeding that reached the areas of the brain. During his time in the unit, the child had epileptic resistance to conventional treatments. During the months of follow-up, the baby evolved Lennox Expenditure Syndromeeven a type of epilepsy that is difficult to control with medication.

The medical team decided to introduce cannabidiol to control epileptic seizures, which until then had been refractory to medication. The new medication, the report says, alleviated the crisis and improved the quality of a child’s sleep. Due to the high cost of the drug, Aguinaldo turned to the health plan and was twice denied supplies because he was not on the ANS list. Disappointed, the father filed a lawsuit to force the health care company to dispense the medication. Three months later, Judge Carlos Eduardo Prataviera, from 5 p.m. The Civil Court of the capital tried the case, giving Aguinaldo a reason.

“It is irrelevant that the procedure does not have the mandatory contractual coverage specified by the ANS because it is part of the contractual coverage provided by the defendant (health plan) and has an express medical indication,” the judge wrote.

The magistrate also ordered the health plan to reimburse Aguinaldo’s expenses with the purchase of cannabidiola within the pre-decision period. According to the administrative coordination, even with the final decision of the STJ, it hopes that it will not reach the decisions already made. “Then the decision must remain valid. I am 10% afraid that something will happen and that the decision that will benefit my son will be overturned, but 90% of my opinion is that it will continue as before. A new decision. I don’t think they will be so inhuman. “I think the new situation is valid from now on. That’s what I’m hoping for, for the good of my son.”

The Washington Miranda estate in Belem, PA, was moved by doctors to ensure the need for a liver transplant was caused by health problems in late April this year. Due to the complexity, the medical team directed the procedure to be performed in a private hospital in São Paulo. When he approached the health plan, he was informed that he was not on the list of procedures included in the operating plan. Miranda went to court and reached a favorable decision. “The judge ordered the health plan to pay the costs. The transplant went well, but I was about to be discharged, after being hospitalized for a month, I had a problem with fluid retention, and he forced me to have new procedures,” he said. .

Miranda was temporarily hospitalized for a total of 48 days of hospitalization, and had the costs covered by the plan, in compliance with the court’s decision. “I’m recovering well today, thanks to God and the punishment of the court. difficulty coping with health, ”he said.

Attorney Rafael Robba, Vilhena Silva Advogados’ health rights specialist, said cases like Aguinaldo’s son could be reviewed in light of STJ’s new understanding. “Cannabidiol is used for a variety of ailments. If the patient has a specific treatment on the list, he or she may have an inappropriate decision if the health plan requires a review of the sentence. he has, ”he said.

According to the lawyer, it was difficult for users of health plans to get treatment that is not on the list, but the judges will be able to judge freely, in their own opinion, despite the STJ summary. “The argument for deletion may lead to a misconception that health plans allow denial of treatment coverage. recommended, heart disease and home help. In addition, health plans also deny coverage for some oral chemotherapies, which are highly complex surgeries that require new technologies, such as robotic surgery. Because of all this, even the STJ understands that the judicialization must continue, ”he said.

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