Health plans leave children without treatment – 05/18/2023 – Market

“Unimed Nacional values ​​transparency in all its relationships. We therefore communicate the termination of the health plan entered into with your company, ending the term of your plan on June 27, 2023.”

Librarian Sadrac Leite Silva, 47, did not understand anything when he received the message from the health operator on April 28th. He and his wife, civil servant Marilene Ribeiro Barbosa, paid the family plan monthly fee, in the amount of R$ 1,458.68, on time, especially because of their eldest son, Leonardo, 8 years old.

Diagnosed with craniopharyngioma, a rare type of tumor that affects the central nervous system, the boy experiences severe headaches, vision difficulties and hormonal problems. In April, Leonardo underwent the third surgery to remove the tumor, which had relapses after being identified for the first time in 2021.

The oncologist who works with Leonardo indicated urgent treatment with radiotherapy after the third surgery, in order to preserve healthy brain cells and prevent a new recurrence of the cancer from reaching the optic nerve, causing the child’s loss of vision. But Unimed denied the treatment. And then canceled the family plan.

In the message in which he informed the cancellation, the operator offered “health care plans in the individual or family modality, without the need to comply with new grace periods, available for cities in the state of Bahia”, although the family lives in the extreme west of São Paulo.

The case of the Silva family is far from being an exception, at a time when health plans are experiencing a crisis. In 2022, the sector registered an operating loss of BRL 11.5 billion, the worst result since the beginning of the historical series, in 2001.

This number refers only to the values ​​obtained with the health services themselves. When considering gains from financial operations, operators had a net profit of R$ 2.5 million. The value represents 0.001% of total revenues, which amounted to R$ 237.6 billion.

In recent weeks, hundreds of agreements have been unilaterally canceled by health plan operators, in what has been seen by lawyers and authorities as a possible way to “clean” the base of the most expensive customers.

Only the office of state deputy Andréa Werner (PSB-SP) received 192 complaints from the end of April until Thursday night (18) – about 90% of them involving Unimed Nacional. The MP-SP (Ministério Público de São Paulo) has just launched an inquiry to investigate the company’s cases. Prosecutors can still open inquiries into cases of other operators.

In second place in number of complaints comes Bradesco Saúde, with 5% of the cases. Other occurrences are divided between four more companies, such as Notre Dame, SulAmérica, Interclínica and São Cristóvão.

Most of the complaints received by the congresswoman –founder of the Instituto Lagarta Vira Pupa, which defends the rights of people with disabilities– involve children with autism, cancer and epilepsy, among other disorders and illnesses.

At Vilhena Silva Advogados, in São Paulo, a specialist in the right to health, there were about 20 cases this year alone involving unilateral cancellation by health plans – most of them from Allianz. As a basis for comparison, in the first four months of last year, there had been only 3.

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 Agency for Supplementary Health), the authority responsible for overseeing health plan operators and for regulating the market.

Business plans have fewer guarantees

“It’s an abusive practice”, says lawyer Rafael Robba, from Vilhena Silva Advogados. “Collective adhesion contracts do not have the same protection as individual and family plans in Brazil”. The latter, according to him, prevent plans from canceling the contract without reason, especially if the patient is undergoing treatment.

“But the individual and family plans have disappeared from the market, the ones that remain are very expensive, the operators offer the collective ones in large numbers, which can be business or subscription [contratados por entidades de classe]. In these, unjustified termination is allowed, with 60 days’ notice,” he says.

If someone in the family has a business registration, a CNPJ, it is common for the family plan to be contracted as a business plan, in the SME (small and medium-sized company) modality.

For lawyer Giselle Tapai, specialist in consumer law with a focus on health, there is an obvious power imbalance between the parties. “People are pushed into a false business plan, a precarious plan, which has abusive clauses and absurd annual readjustments, of 80% or more”, she says.

With Sadrac Silva it was like that. “I paid for a subscription plan that was getting much more expensive, around R$2,000. I followed the advice of the insurance broker, who suggested that I open a company as an individual micro-entrepreneur [MEI]to get a more affordable plan, around R$ 1,400”, he says. “But there is a catch there, because the business plan makes us more fragile in negotiating with the operator.”

Silva filed a lawsuit against Unimed and, on the 11th, managed to get the company to comply with an injunction to maintain Leonardo’s treatment. But the cancellation of the plan, scheduled for June, continues.

According to Giselle Tapai, experience shows that it is not enough to complain to the ANS, as nothing changes for the operators. “Consumers are obliged to seek the Legislature to have their rights assured”, says Giselle.

STJ understands that patient undergoing treatment cannot be disqualified

According to Rafael Robba, there is an understanding of the STJ (Superior Court of Justice) that, even in collective plans, if the patient is in treatment, the plan must guarantee the continuity of assistance until his discharge, as long as he continues to pay the monthly fee. “The plan can only be canceled in case of fraud or default”, he says.

Deputy Andréa Werner, who chairs the Permanent Commission for People with Disabilities at Alesp (Legislative Assembly of the State of São Paulo), points out that families do not stop paying for health plans, because they need the service very much —in the SUS (Sistema Único de Saúde) the service can take months to happen. Werner was the author of the complaint with the MP-SP (Ministério Público de São Paulo), which has now been upheld.

Débora Mello, 28, is Lorenzo’s mother. Currently 7 years old, the son was diagnosed with autism at 3. “Today he is a child who socializes, he is in the 2nd year of elementary school, in the literacy phase”, says Débora. “It is a very important period, therapeutic follow-up guarantees his evolution. But Unimed canceled Lorenzo’s plan and the last consultation was on May 4”, she says, who saw the monthly fee double in the last year, for R $811.

“We have already filed a lawsuit against Unimed due to the absurd readjustment, which even so continued to be paid, with no day of delay”, says Débora, who complains about the slowness and bureaucracy in the operator’s service for common matters, such as issuance of guides.

“But now they canceled the plan and it would be completely unfeasible for our family to maintain a private treatment, in the range of R$ 7,000 per month”, says she, who is a psychology student and works as a therapeutic companion, while her husband works in the area of technology. They also went to court over the cancellation.

OTHER SIDE: Operators say that cancellation is regular; ANS says there is portability

Sought, Unimed replied that “the unilateral termination of collective health plan contracts is a possibility provided for in the contract and in the sectoral rules defined by the ANS. When they happen, the terminations are communicated in advance to the beneficiaries and are never done in a discretionary manner, discriminatory or with the intention of restricting people’s access to treatments.”

Qualicorp stated that “it is a health plan administrator and acts as an intermediary, hiring is optional. The operator is responsible for the care network.”

Bradesco Saúde said that “it does not terminate contracts for any reason related to the coverage contracted and in disagreement with the contractual conditions agreed between the parties”. Allianz said that “the process of discontinuing the offer of the Health product is being carried out in an organized and duly structured manner, respecting the parties involved”.

FenaSaúde (National Supplementary Health Federation) and Abramge (Brazilian Association of Health Plans), which represent these and the other health plans mentioned, also pointed out the ANS rules. According to FenaSaúde, “the main objective of our operators is to keep their beneficiaries always well attended, making use of management actions, cost control, combating fraud, abuse and waste, encouraging the conscious use of plans and defending the adequate incorporation of new technologies”.

Abramge informed that “when the collective agreement is terminated, by demand of any of the parties, the beneficiaries linked to it have the right to carry out the portability and, thus, contract a new health plan without the need to wait again for the fulfillment of the shortcomings”.

Through its press office, ANS informed that “in collective plans, there may be two situations for canceling the plan: the occasional exclusion of a beneficiary or the termination of the contract between legal entities (the contracting company and the operator) to request of either party”.

According to the agency, “in legal entities, after the term of validity of the collective agreement, contractual termination without cause may occur, and must always be preceded by notification, observing the contractual provisions, which are subject to the Consumer Protection Code”.

The ANS stated that it provides a booklet with information on the portability of shortages.