The judge orders the health plan to compensate the client for refusing treatment

It is not the health plan's job to decide how to treat a patient, that is the role of the trusted physician who cares for them. Denial of treatment on the basis that it is not included in the National Health Agency's list of complementary procedures is arbitrary.

This was the understanding of Judge Marcos Aurelio Gonçalves, of the Single Court of Nazaré Paulista (SP), convicting a health plan operator for compensating a woman diagnosed with Crohn's disease who refused the treatment recommended by the doctor.

A claimant who is denied admission to the hospital will be compensated under the health plan

The author states in the lawsuit that she was diagnosed with Crohn's disease and was referred to the hospital, but the operator refused her request and claimed that she could only be admitted to one of the network's hospitals, without providing an ambulance.

The complainant claims that she was not discharged from the hospital due to her clinical condition. Then she filed a lawsuit against the judiciary, demanding proper treatment and compensation for moral damages.

The judge indicated in his decision that the dispute must be decided on the basis of the Consumer Protection Law, and that it was proven that a specialized doctor indicated the need for hospitalization for treatment.

“Now, if there is a prescription, as we mentioned previously, refusal to adhere to the indicated treatment is considered an abuse. It is worth noting that only the specialist doctor is able to adequately assess the patient’s health condition and prescribe the necessary and appropriate treatment. He pointed out that it is not within the plan’s jurisdiction Health care has to decide how to treat the patient, and this is the role of the trusted doctor who helps them.

He also noted that Precedent 102 of the Court of Justice of São Paulo states: “If there is an explicit medical indication, it is arbitrary to refuse to cover the costs of the treatment under the pretext of experimental nature or because it is not included in the list.” of ANS procedures.”

Finally, the judge ordered the health plan operator to compensate the consumer in the amount of R$10,000 for moral damages.

The author was represented by lawyers Clipper Stevens Garage that it Carmen Franco.

Click here to read the decision
Process 1001520-27.2023.8.26.0695