New reimbursement requirements for health plans | File a complaint in advance

I submitted a request for a refund of R$1,000.00 for a colonoscopy on 03/05. I should receive it within 30 days, but nothing yet. When contacting the health plan, inform them that there is a pending issue, which requires a receipt with the pixel provided to the doctor. This is correct? I always paid the doctor with a post-dated check, and he would receive it after the payment was made. (Regina do Nascimento, Anil – RJ).

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According to Melissa Ariel Peres, a lawyer specializing in health law, the terms of payment must be specified in the contract, including the deadline for implementation and the documents that the patient must provide. He highlights that “requirements, under the plan, that are not foreseen in the contract, or, if foreseeable, place the patient at an excessive disadvantage, are questionable.”

Recently, some health plans have begun to require proof of a bank transaction related to the service provided, in response to the rise in fraud, a measure that has made it impossible to reimburse patients who do not have the policy and are surprised by a negative response called “de-payment.” Previously, patients were able to obtain reimbursement before making payment, submitting only medical documentation and the invoice, and adjusting directly with the provider the form and date of payment, such as cash, installments, or after receiving payment.

In these cases, there is no proof of disbursement, and refusal to pay due to the absence of this document is considered arbitrary, as it causes exaggerated harm to the patient. “Even without compensation, the patient will have to legally fulfill the debt of assistance incurred by the provider, confident that they will receive compensation,” Melissa concludes.

This practice not only harms patients financially, but also violates contractual principles and good faith, generating further tension in the already complex relationship between consumers and health plans, highlights attorney Atilla Nunes of the service www.reclamar advanced com br. The service is free via email [email protected] or via WhatsApp (21) 993289328.

Cases are solved by the Reclamar Adianta team (WhatsApp:21 -99328-9328 – for messages only): Mauro Beckman (Claro), Ana Machado (Hi), Ivone Molina (Hi).