Post by account_disabled on Jan 30, 2024 11:05:18 GMT
The health plan cannot refuse to pay for a treatment prescribed by the doctor if the illness is covered by the plan. This was the understanding of judge Andrea de Abreu e Braga, from the 10th Civil Court of São Paulo, when obliging the health plan to pay for medication for home use. In this case, the man underwent a liver transplant, and the doctor prescribed continued use of the medication Everolimus. However, the patient's health plan refused to guarantee coverage of the medication, arguing that, as stipulated in the contract, the medicine for home use is not covered by the health plan.
According to the agreement, Law 9,656/98, which Buy Phone Number List regulates health plans, exempts the operator from paying for medication administered in a home environment, which led the patient to discuss the issue in court. Represented by lawyer from Bueno , the patient claimed that this type of denial is abusive. The lawyer explained that the Superior Court of Justice has a pacified understanding in the sense that the place of administration of the medication is irrelevant to defining the obligation of coverage by the health plan. "Once the illness is covered, treatment, including the necessary medication, must be guaranteed, and the Consumer Protection Code allows us to conclude that any contractual clause to the contrary is null and void," he stated.
When judging the request, judge Andrea de Abreu e Braga followed the STJ's understanding, classifying the refusal of the health plan as abusive. "Denying a curative procedure or one that brings a better quality of life to the patient is the same as withdrawing coverage for the disease, which is abusive. The thesis that funding must be provided in the form of reimbursement does not succeed, as it is a formula that is harmful to the consumer", said the judge. Supreme Court Precedent When judging the company's appeal, judge João Pedro Cavalli Júnior, rapporteur, understood differently. For him, the presumption of innocence was not “the least bit scratched” in the case. First, because the conviction did not, in itself, violate this guarantee, as the process was not under judicial secrecy.
According to the agreement, Law 9,656/98, which Buy Phone Number List regulates health plans, exempts the operator from paying for medication administered in a home environment, which led the patient to discuss the issue in court. Represented by lawyer from Bueno , the patient claimed that this type of denial is abusive. The lawyer explained that the Superior Court of Justice has a pacified understanding in the sense that the place of administration of the medication is irrelevant to defining the obligation of coverage by the health plan. "Once the illness is covered, treatment, including the necessary medication, must be guaranteed, and the Consumer Protection Code allows us to conclude that any contractual clause to the contrary is null and void," he stated.
When judging the request, judge Andrea de Abreu e Braga followed the STJ's understanding, classifying the refusal of the health plan as abusive. "Denying a curative procedure or one that brings a better quality of life to the patient is the same as withdrawing coverage for the disease, which is abusive. The thesis that funding must be provided in the form of reimbursement does not succeed, as it is a formula that is harmful to the consumer", said the judge. Supreme Court Precedent When judging the company's appeal, judge João Pedro Cavalli Júnior, rapporteur, understood differently. For him, the presumption of innocence was not “the least bit scratched” in the case. First, because the conviction did not, in itself, violate this guarantee, as the process was not under judicial secrecy.