The Second Section of the Superior Court of Justice (STJ) decided on Wednesday (8) to restrict the procedures offered by health plan operators in the country.
The ministers defined that the nature of the role of the National Supplementary Health Agency (ANS) is exhaustive, which exempts companies from covering medical requests that are outside the list.
The understanding affects the approximately 49 million Brazilians who have health care plans.
Understand more about the decision and learn how to consult the full list:
What is the role of the ANS?
The ANS list consists of a list of “procedures considered essential for the diagnosis, treatment and monitoring of diseases and health events” that the country’s medical assistance plans are required to offer.
The mandatory procedures, however, vary according to the type of plan signed: outpatient, hospital – with or without obstetrics –, referral or dental.
The current list was approved by the ANS in February 2021 and went into effect in April of the same year. The more than 3 thousand procedures listed can be consulted on the agency’s website.
What is the difference between exhaustive and exemplary interpretation?
In the exemplary interpretation, the list of procedures covered by the plans contains some items, but the operators must also attend to others that have the same purposes, if there is clinical justification from the responsible physician. This allowed families to go to court so that the right to coverage by the plan was guaranteed.
In the exhaustive interpretation, the items described in the list would be the only ones that could be required from the plans. As a result, the request for equivalent treatments could be denied, with no chance of judicial recognition.
Why was the STJ discussing the nature of the ANS role?
The Court has been evaluating two appeals since September 2021.
They sought to standardize the internal jurisprudence of the court, so that there are no different understandings — that is, divergent decisions of the same Court, as was the case.
What did the STJ decide?
The STJ decided to restrict the procedures offered by health plan operators in the country.
Six of the nine ministers that are part of the collegiate voted in favor of establishing the taxing list, which exempts companies from covering medical requests that are not provided for in the ANS list.
The decision was based on the exhaustive role, but are there exceptions?
If there is no therapeutic substitute or the procedures on the list are exhausted, there may be exceptional coverage of the treatment indicated by the doctor or dentist.
But, for this, it is necessary that: the incorporation of the procedure to the list has not been rejected by the ANS; there is proof of the effectiveness of the treatment in the light of medicine; there are recommendations from renowned national and foreign technical bodies, such as Conitec and Natjus; whenever possible, the inter-institutional dialogue of the magistrates with experts in the health area is carried out, without shifting the competence of the judgment of the case to the Federal Court.
What is the position of groups of fathers and mothers of children with disabilities?
Consumers and groups of parents with disabilities advocated the exemplary interpretation.
They point out that the role is insufficient and that the ANS does not update the list effectively.
Therefore, they fear the interruption of treatment of cancer patients and children with autism, for example.
“Since medicine is a (always) developing science, the list cannot be exhaustive under any circumstances under the risk of killing a person,” said Vanessa Ziotti, legal director of Instituto Lagarta Vira Pupa. The institution now intends to go to the Federal Supreme Court (STF) to challenge the decision of the STJ.
What was the understanding of the ANS itself?
The ANS points out that the taxation of the list has been imposed by law since 2000.
To Estadão, the agency also highlighted that, as it is an “extremely sensitive measure in the health insurance market”, it has been improving the rite of updating the list.
“Making it more accessible and faster, as well as ensuring extensive social participation and prioritizing the safety of incorporated health procedures and events, based on the most modern ATS (health technology assessment).”
What did the operators stand for?
The operators asked for the taxing role. This is for two main reasons: more legal certainty and because the list is used to set the price of plans.
“Formulating the price of a product with no coverage limit, which includes any and all existing procedures, drugs and treatments, can make access to a health plan unfeasible and put the continuity of supplementary health in Brazil in check”, declared the Association. Brazilian Health Plans (Abramge), to Estadão.
Source: CNN Brasil
I’m James Harper, a highly experienced and accomplished news writer for World Stock Market. I have been writing in the Politics section of the website for over five years, providing readers with up-to-date and insightful information about current events in politics. My work is widely read and respected by many industry professionals as well as laymen.
