Last week, the Superior Court of Justice (STJ) postponed the decision if the list of procedures defined by the National Supplementary Health Agency (ANS) should be considered exemplary or exhaustive.

Written by Heloisa Vasconcelos

Last week, the Superior Court of Justice (STJ) postponed the decision if the list of procedures defined by the National Supplementary Health Agency (ANS) should be considered exemplary or exhaustive. rol de procedimentos definidos pela Agência Nacional de Saúde Suplementar (ANS) deve ser considerado exemplificativo ou taxativo.

The decision must be defined within a period of up to 90 days, when the topic will be discussed again. The STJ judgment can have an immediate impact on health plan usersespecially people in need of specific treatments. usuários de planos de saúde, sobretudo pessoas com necessidade de tratamentos específicos.

The ANS has a list of more than 3 thousand types of consultations, exams, therapies and surgeries with mandatory coverage by health plans. Today, however, policyholders who need a procedure that is not on the list can go to court to guarantee coverage under the plan.

If the STJ deems the list of procedures to be exhaustive, health operators will only have to cover the items defined by the ANS list.

Exemplary or Exemplary?

Two views on how to interpret the ANS list of procedures divide the STJ ministers: whether it is a fixed list or just a suggestive one.

“The tax is a closed list and if it is not there, the person will have to pay out of pocket. The example is what we have today, the health plan has to cover regardless of whether or not it is on the ANS list”, summarizes a lawyer specializing in medical law and a master in law from PUC-SP, Washington Fonseca.

For the president of the Ceará Consumer Protection Association (ACDC), Thiago Fujita, the interpretation of the list as exhaustive makes it difficult for consumers to access more specific procedures, mainly affecting people with serious illnesses or special needs.

He adds that the list has not been updated for some time. Limiting the coverage of health plans, according to him, means that the insured has to pay out of his own pocket to have access to procedures that can be important for the patient’s life.

However, there is a great concern about plastering health coverage, noting that we are dealing with the health and life of the consumer. When there is a refusal, the consumer often has to go to court and, as an example, the judge has the interpretation of who should decide [a cobertura ou não] is the doctor

THIAGO FUJITA

president of ACDC

Washington also points out that the STJ’s decision can lead a greater number of people to seek the SUS, which can be overwhelmed.

“The issue is that if this tax decision remains, people will continue to pay for the health plan, but if they have a disease that is not on the list, they will have to pay out of pocket. People will have a greater tendency to migrate and look for SUS even with health insurance”, he explains.

Price of health plans 

Washington Fonseca considers that there should be no change in the price of health plans depending on the decision of the STJ.

He states that operators will not lower prices or reduce readjustments, even in the face of the smaller number of procedures to be covered if the list is considered exhaustive.

The lawyer compares the situation with the decision on the payment of checked baggage in the airline sector. “It was said that the price of tickets would decrease, but that’s not what we saw”, he defends.

“Decreasing prices is not something consumers can expect. What they can say is that the readjustments will have a smaller perspective because they have predictability. But I’ve been working in consumer law for 15 years, I don’t believe it”, emphasizes Thiago Fujita.

In a note, the ANS defended that the List of Procedures and Events in Health is exhaustive. And, as an example, there could be an impact on the definition of prices.

Vale destacar ainda que, além da falta de padronização das coberturas, o caráter exemplificativo do rol – por não conferir previsibilidade quanto aos procedimentos e eventos que podem vir a ser utilizados – tenderia a elevar os valores cobrados pelas operadoras aos seus beneficiários, como forma de evitar a sustentabilidade de suas carteiras ANS

Regulatory actions 

According to the agency, the list serves as a basis for regulatory actions to be applied, such as inspection of coverage, collection of reimbursement to the SUS and definition of the solvency and liquidity margins of operators.

The ANS also reiterated that it “has been systematically improving” the process of updating the list, so that it is agile, accessible and in line with the most modern in medicine.

“Assuming that the list is merely exemplary means, at the limit, attributing to each of the judges in Brazil the prerogative of determining the inclusion of coverage not provided for in the contract or in the list of minimum coverage, which would bring about an increase in judicialization in the sector of and enormous insecurity to the supplementary health sector, insofar as it would be impossible to adequately measure which risks would be effectively covered. Which impacts on the definition of the price of the products”, he highlights.

Source: DIÁRIO DO NORDESTE –  https://diariodonordeste.verdesmares.com.br/negocios/como-a-decisao-do-rol-da-ans-pode-impactar-a-cobertura-para-clientes-de-planos-de-saude-1.3198639