Health plan: 4 stories of loss of coverage – 05/18/2023 – Market

Carla da Rocha Costa, 44, and her wife saw the health plan for both of them and their 11-year-old daughter Izadora, who is autistic, canceled for no reason. Bradesco Saúde’s monthly fee was R$2,452, paid on time.

“The lawyer said it was practically a won cause, because Izadora was undergoing treatment. But we don’t have that money”, says Carla, a physical education teacher, while her wife works in the health area.

The alternative they found was each to sign a new agreement with other operators, in order to increase the coverage of their daughter, who entered as a dependent. “Either we paid for a new plan, or we paid for the lawyer. We didn’t want to risk it. If we didn’t get the court decision, Izadora would be without any assistance”, she says. In the private network, the daughter’s treatment would cost R$ 20,000 a month.

after the Sheet contacted Bradesco Saúde to find out the reasons for the unilateral termination of this and other cases, Carla’s daughter’s plan was activated again. “They said that there was an operational failure in sending the letter that communicated the cancellation, in February”, she says.

Carla had contacted the operator, questioning the cancellation, but at the beginning of March she received a response that the termination was “a prerogative of the insurer in line with the contractual provision.”

Their case adds to similar ones, in which children with long-term treatments have lost coverage. The problem began to be investigated by the Public Ministry, which opened an investigation this Thursday (18).

Questioned by Sheet, health operators say they are within the law, because unilateral termination is provided for in the contract. The position is shared by the ANS (National Supplementary Health Agency), the authority responsible for overseeing health plan operators and market regulation.

“Families are in an extremely vulnerable position”, says lawyer Rafael Robba, from Vilhena Silva Advogados, a specialist in the right to health. “They pay a health plan to use when someone gets sick. But what we see are operators terminating contracts when the use is constant, because they consider it costly”, he says, who also received about 20 complaints related to the same problem in the office this year. .

The expert draws attention to the practice in cases of children with rare syndromes, cancer or autism, in which the treatment will be long-term or for life. “It’s as if the operators only wanted healthy adults as beneficiaries, who pay for the plan and rarely use it”, he says.

Discover the stories of three other children, as told by their parents.

Marina, 5, as reported by her mother, Érika Thaís Mariano

Marina was diagnosed with autism two years ago. Therapy is what will guarantee her quality of life in the future. Until the age of 3, she did not speak, she only gestured. Today she is able to communicate, express feelings, but this is after persistent, continuous work.

My husband is an app driver, I work with customer service. Today she goes to school with therapeutic follow-up, then goes to the clinic. If we had to pay for this service, it wouldn’t cost less than R$30,000 a month. It is something impossible to pay.

I am part of a WhatsApp group with more than one hundred mothers of autistic children. It is a very lonely struggle for mothers, who end up leaning on each other. Many had their agreement canceled in April. All, including me, with Unimed. They told me that “the necessary index to maintain the quality of the services would become unfeasible”, and that for this reason the contract would be terminated on May 31st.

In the last year, the price of the Marina plan practically doubled, going from R$358 to R$689. I was hoping that now, in May, there would be a new readjustment, but what happened was a cancellation. They don’t care about us, about my daughter’s health. We are just a number that no longer makes sense to them.

Manuela, 9, as reported by her father, Théo Artioli Azevedo

In August of last year, we found out that Manu has a bone tumor on her left femur. We decided to upgrade our health plan to give her the best care we could afford. Today, my family plan, for two adults and two children, costs BRL 5,592.

But this change was not immediately accepted by Unimed. We had to file a lawsuit to avoid having to go through the six-month grace period – which is absurd, considering the same health plan. We got the injunction and she underwent 12 chemotherapy sessions.

In one of them, there was a complication, he almost went into sepsis [infecção generalizada]. For some reason, Unimed denied the hospitalization. I had to hastily increase the limit on my card to R$20,000 to get my daughter admitted in time. Once again, I resorted to Justice to be compensated.

My wife was a holistic therapist and had to stop working to accompany Manu. I am a partner in a communications company. We have another son, 7 years old. We never needed to use the plan, it was always for Manu.

She had surgery to remove the tumor in January. It was a complex intervention, because she also received a femur and knee prosthesis, made in Germany, at a cost of BRL 400,000. Unimed did not accept the doctor we chose, they wanted to impose another name. I thought: I need to choose which battles to fight. I decided to make a deal, in which Unimed paid for the prosthesis and I paid for the surgery with Manu’s doctor. We disbursed R$40,000, a good part of our savings.

Manu still needs chemotherapy to avoid the risk of metastasis or a recurrence of the cancer. And now that we were seeing the finish line, Unimed canceled the plan.

My daughter, who is only 9 years old, sees my wife crying, I nervous, both of us tired of demanding a little dignified care. She comes crying to us apologizing, thinking it’s her fault everything we’re going through. I don’t have the emotional structure to deal with this anymore.

Gabriel, 5 years old, as reported by his mother, Érika Lima Sacheto

Gabriel has been epileptic since he was born. At five months old, he was diagnosed with West syndrome, which also causes spasms and neuropsychomotor development regression. It’s something that can cause 50 seizures a day. I only discovered the disease when he stopped smiling.

Even today he wears diapers and cannot stand on his own. He is learning to chew. But the progress we’ve made so far is due to therapeutic care, which was suspended by Unimed.

I contracted the health plan through Qualicorp when Gabriel was 3 years old. I said right away that he was a child with epilepsy. We fulfill the grace period of 6 months.

After facing the pandemic period in prison, we managed to do face-to-face treatment at the clinic in the last year. It took him a while to adjust to the therapists, but he made tremendous progress by getting to his feet and taking a few steps. For starting to chew.

Therefore, when I received the email from Qualicorp informing that I no longer had an accreditation with Unimed, my world fell apart. I asked for an alternative but was told they had no offer at the moment.

I went to court against the rescission and we got an injunction on April 28th. Both Qualicorp and Unimed are defendants in the lawsuit. But as the judge did not stipulate a fine, nobody complied. I called Unimed and they hung up on me. Qualicorp at least assists me, but does not solve anything.

This whole situation aggravates my anxiety, I’ve been having panic attacks. The life of an atypical mother is full of exclusions. But a company, which is being duly paid to provide a service, has no right to exclude my son’s chances of progressing. Therapy will define how much autonomy he will have in the future.

I know dozens of mothers who are in the same situation, desperate, with their health plan cancelled.

I was a sales coordinator, but I resigned to accompany Gabriel in his treatment. My husband works full time. We were paying R$1,500 for the family plan, after the last increase of 22%. I do handicrafts, I stay up all night to pay for health insurance. I don’t deserve to be treated like dirt.