A decision by the Federal Prosecutor’s Office (MPF) not to uphold an appeal from a health insurance scheme contesting the reimbursement of a beneficiary who paid for prostheses, orthoses and accessories, highlighted the application of the Consumer Code in the relationship between operators and customers. The operator’s request comes after the development of a Public Civil Action filed by the patient.
On the occasion, the Deputy Attorney General of the Republic, Juliano Baiocchi, analyzed an appeal request from Golden Cross International Health Assistance, which was trying to overturn a court decision that guaranteed a beneficiary financial compensation for having paid prostheses, orthoses and accessories. In the decision, it was understood that the company had acted improperly by refusing authorization for a heart procedure in which the purchased items would be placed.
In this sense, the Deputy Prosecutor, by not acceding to the company’s request, recognized the possibility of an impact of the Consumer Code on private relationships related to health care, “in particular, in the provisions that prohibit the existence of unfair terms, as is the case in the case file”, underlined the MPF.
For the legal director of the Institute for the Defense of Consumers and Taxpayers (IDC), Renata Abalém, the opinion of the MPF confirmed, on the basis of the decisions of the superior courts, the obligation of the plans to reimburse the beneficiaries who have had to pay for a procedure refused by the operator. As it is a public civil action, reinforces the lawyer, the decision can be used by other clients in a similar situation.
“The action dates from 2003, so all consumers who have paid for orthotics, prostheses and accessories and whose claim for reimbursement has been refused, will be entitled to make this decision and to carry it out. That is- that is, you just have to charge the plan the amount spent,” explained Abalém, who is also a member of the Consumer Law Commission of the Brazilian Bar Association of São Paulo (OAB/SP).
The expert emphasized that the Consumer Code should be the guiding standard for relations between beneficiaries and companies responsible for health plans. “The code cannot be used only when it comes to self-management plans. I give an example to Geap Autogestion (scheme for civil servants). The courts understand that the relationship with self-directed plans is not a relationship that should be supported by the Consumer Protection Code. The other plans are covered and the rules of the consumer defense code are respected,” reinforced Renata Abalém.
Also according to the director of the IDC, health plans have taken customer requests to extreme situations of denial of beneficiary requests. “It’s a constant struggle, so much so that some courts have created several health specialists. It’s cheaper to argue in court, ”underlines the lawyer who calls for a more proactive attitude on the part of the National Complementary Health Agency and consumer rights protection bodies, such as Procons.
“I think I should take a closer look. Not only the ANS, but also consumer protection bodies should act faster and not just wait for the consumer to file a thousand complaints. These are bodies that have the legitimacy to act,” Abalém concluded.
Contacted, Golden Cross did not comment on this.
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