The autistic son’s father regrets the STJ’s decision on health plans: “There are few people who can afford these treatments” | Campinas and the Region

“Few people are able to afford these treatments. They are expensive and long-term. I hope my parents continue to win lawsuits against the plans. The benefit is huge,” he says.

  • Health plans should not cover procedures outside the ANS list, the STJ has ruled

Almir Maxiê is the father of 24-year-old Durigo Severino, who has had crises since the first year of his life. After being diagnosed with West Syndrome, the young man underwent various treatments with regular medications until he received a recommendation from a neurologist to use cannabidiol.

The problem is the cost of treatment. According to Almir, who asked for permission from Anvisa and obtained the medicine in the first months of treatment, a five-ml bottle lasting five days costs about $ 150 – the equivalent of R $ 735 at the current price. . .

“The cost of almost 5 thousand R $ per month is something that is not feasible, although it will always need follow-up. It is not for the short term,” Almir said.

  • Understand, in four points, what the STJ has judged
  • The ANS supports a 15.5% increase in individual health plans: understand how it will work

24-year-old cannabidiol pot used in the treatment of Maxiê, a resident of Campinas (SP) – Photo: Personal archive

According to the young man’s father, the use of drugs brought two gains to his family. From a few dozen days to a few days he stopped controlling crises, from time to time, and improved behavior and interaction.

“With Cannabidiola, he was more attentive, before he seemed to forget everything. He didn’t say anything, but he started to pay more attention, he started interacting with gestures, pointing, things he didn’t do. It’s very significant for us,” he explained.

Appellate process

Lawyer Fabio Camata, representing Maxiê’s family, explained that the process that guarantees the treatment has been tried in the first instance and is being appealed to the São Paulo Court of Justice (TJ-SP).

“The draft is already in place and the plan is in full swing. Today, at this particular time in TJ-SP, our understanding is that there is a precedent in force, the result of court case law. that they are there, even if they are not included in the ANS list, ”explained the lawyer.

According to Camata, the possibility of exemptions provided for in the STJ decision widens the debate on the cost of medical treatment outside the so-called tax role.

Health plans: what can be changed in the coverage of the STJ ruling

What does the STJ’s decision say?

Six of the nine ministers who voted in the second section understood the call list of procedures ANS it is accurate, that is, the list contains not only examples, but all the coverage obligations for the health plan.

The decision includes coverage for testing, therapy, surgery, and drug supply, for example.

The decision of the STJ does not oblige the rest of the court to comply with this understanding, but the ruling serves as a matter of law for the Judiciary.

STJ’s understanding represents a changing the jurisprudence applied by most courts in the countryhe understood that the role was just an example.

The decision sets out exceptions

Understanding that the list is accurate modulated the STJ ministers to allow for some exceptions; for example, therapies specifically recommended by the Federal Medical Council (CFM), anti-cancer treatments, and “off-label” medications (used). prescription for treatments not included in the package of this medicine).

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.

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