The First Chamber of Private Law of the Court of Justice of São Paulo ordered the health plan to pay the costs of treating a patient diagnosed with bipolar disorder with the medications prescribed for him, under penalty of a daily fine of R$1,000.
According to records, appellant was discharged from a psychiatric hospital and activated a health plan to continue treatment with his prescribed medications. However, the Respondent rejected the application, claiming that there was no provision in the list of mandatory measures of the National Agency for Supplementary Health (ANS).
The rapporteur of the ruling, Judge Alexandre Marcondes, confirmed the understanding of the Supreme Court, according to which the comprehensiveness of the ANS list cannot be absolute, and it is up to the judiciary “to impose the cost of treatments when structural damages and systematic deficiency are proven in the list prepared by the authority responsible for complementary health in Brazil.”
According to the judge, the health plan can determine which diseases will be covered, but not the form of diagnosis or treatment. “The recommendation to carry out treatment is of a medical nature, and the professionals who assist the author are those who have knowledge of her needs. He noted that it is their responsibility to provide treatment guidance, and the operator has no right to refuse coverage, on pain of endangering the patient’s health.
The jury was completed by judges Augusto Rezende and Iñas Costa García. The decision was unanimous.
Appeal No. 1000521-33.2023.8.26.0547
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