What What should I do if my health plan denies surgery or exams?

What to Do if My Health Insurance Plan Denies Surgery or Tests

Every month you pay your plan's monthly premiums, and when you need it most, it refuses to release a test or surgery request. Unfortunately, many people experience this kind of unpleasant situation because the provider claims it's not obligated to cover the procedure.

They claim it's not on the National Supplementary Health Agency (ANS) list, so they don't need to comply. However, see this post for what you can do if this happens, especially in urgent and emergency cases.

When the operator denies any type of procedure, it must communicate this to the beneficiary in writing using clear language, indicating the contractual clause or legal provision that justifies the denial.

Please note that the List of Procedures already includes more than 3,195 procedures.

However, you need to be aware of the type of health plan you have purchased, as each type includes different coverage.

For example, those with outpatient coverage are only entitled to care and exams performed in outpatient clinics or offices. In other words, surgeries and hospitalizations are not included.

However, remember that health insurance providers cannot determine the types of treatments that beneficiaries should undergo.

Why did the operator deny my request?

One of the justifications given by insurance companies is in relation to the doctor's conduct when prescribing a particular treatment, as he or she may request a technique that the plan does not cover.

The problem is that all diseases have mandatory coverage, however, not all treatments are permitted.

However, the patient can appeal to the courts, claiming that the treatment is the most appropriate, as long as it is performed appropriately. Everything must be proven, substantiated, and documented.

Health Insurance Denies Surgery or Exams

Another point is that insurance companies believe they should only cover the minimum mandatory procedures. However, the Brazilian court system understands that despite the minimum coverage list, insurance companies cannot define the best therapeutic procedure for each patient.

If the person has already paid for the service, they can still demand direct reimbursement of the amounts.

What other cases do health plans deny care in?

• Waiting period: However, the ANS sets a maximum waiting period, which is 24 hours for urgent and emergency care, 300 days for full-term births, and 180 days for all other situations. The provider cannot establish a waiting period longer than that stipulated by the ANS;
• Pre-existing conditions, such as cancer. Partial coverage is available for the first two years;
• Bariatric surgeries: even though obesity is considered a disease (see our content on the subject here), some insurance companies think it is for aesthetic reasons and end up not covering the procedure;
• Surgeries involving prosthetics, orthoses, stents, and valves: although the policy does not cover these procedures, it is possible to have the provider cover medical expenses.
• Impediment to various exams: normally, they deny the most expensive exams;
• Difficulty obtaining medication.

Appeal to the defense agencies

The first thing you should do in this situation is to inform the ANS (National Health Regulatory Agency). According to the agency, the operator cannot deny service because it is aware of the risks involved in this market.

Furthermore, the beneficiary may appeal to the courts to demand that the plan cover the expenses. Interestingly, all Brazilian courts have a judge on duty to handle urgent cases, even when the courts are in recess.

But, even when there is no urgency, you can resort to the courts, ANS and consumer protection agencies.

How to file a lawsuit?

In Brazil, the courts are increasingly filled with lawsuits against health insurance companies. However, the majority of these cases (more than 90%) resulted in favorable rulings for the beneficiary, including compensation for moral damages.

The way you appeal will depend on the value of the procedure denied, being able to go to small claims court and even file a lawsuit without the presence of a lawyer.

Furthermore, be aware that the Consumer Protection Code may apply and, therefore, request the execution of procedures, reimbursement of expenses you were forced to incur and demand compensation for moral damages, as such situations tend to generate psychological stress.

Guidelines in case of denial of health plan coverage:

So, now that you know your rights, when you receive a denial, follow these tips:

• Gather all possible information: medical reports, exams, medical report results;
• Ask the health insurance company to formalize the refusal in writing: this will help to prove the lack of authorization.
• Register with ANS and also with Procon: especially in situations that do not require urgency;
• Look for a trusted specialized lawyer.