Readjustment of collective health plan reaches almost 60% – 01/04/2023 – Market

Readjustment of collective health plan reaches almost 60% – 01/04/2023 – Market

Silvio Kouyoumdjian, 53, has been a beneficiary of the collective health plan by membership linked to the Union of Engineers in the State of São Paulo since 2006. When he contracted the agreement, he paid BRL 664 for him and his wife. The value has increased over the years and, with the readjustment of 59.8% expected for 2023, the economist will pay more than R$ 8,500 monthly starting this month.

This amount would be even greater if Kouyoumdjian had not gone to court against the adjustments that he considers abusive and won the lawsuit, which started in 2019. 8,500 predicted. If he had lost the case, the monthly fee would exceed R$ 18.5 thousand.

The economist says that, in recent years, the agreement has gone through a series of increases above inflation, which have exceeded the percentage applied to individual and family health plans, whose readjustment ceiling is defined by the ANS (National Agency for Supplementary Health).

In a note, Amil Medical Assistance, the operator responsible for the plan in Kouyoumdjian, says that the calculation of the readjustment of plans by adhesion considers the costs of collective use in the previous period and also medical inflation, with technical and financial indices that vary according to each client. .

Lucia de Queiroz Novaes, 100, was also surprised by the increase in her plan. The monthly fee rose from R$ 8,500 with a 30% readjustment in March of this year. She joined the collective membership plan linked to Simpi (Union of Micro and Small Industry of the State of São Paulo) in 2021, for the amount of R$ 5,700.

His son, Eduardo de Araújo Novaes, 73, says he has already paid this month’s bill and opines: “The readjustment was totally abusive. There is nothing that justifies this increase.”

SulAmérica, responsible for Lucia’s agreement, says that the readjustment, provided for in contracts, takes into account the rules of the sector to maintain excellence in the continuity of the offer of medical assistance.

Qualicorp, the benefits manager, says it acts in defense of consumers, negotiating the lowest possible readjustment. In the case of the 59.8% increase, he says that the “portfolio in question has only 30 customers”, and that it offers about 700 products from more than a hundred operators “as an alternative so that its customers can maintain access to quality health .”

Regarding Lucia’s case, the administrator states that the portfolio in question adds up to 0.03% of the total number of her clients.

On behalf of operators such as Bradesco Saúde, Amil Assistência Médica and SulAmérica, FenaSaúde (National Supplementary Health Federation) states that the annual readjustment is influenced by factors such as the price of medicines and medical supplies, growth in the use of plan services and the incorporation of new mandatory coverages, such as medications and procedures.

“The readjustment of health plans is indispensable to recompose the variation in costs, guaranteeing the continuity of the offer of medical assistance to its beneficiaries”, says the note.

Abramge (Brazilian Association of Health Plans) states that the annual readjustments aim to maintain the balance between the use of services by beneficiaries, the quality and modernization of the health system and advises that people seek to evaluate new options for agreements.

“As they do in the market with different day-to-day products, it is also necessary to seek better prices for health plans.”

Unimed do Brasil reported that the percentage is defined in the contract based on free negotiation between operators and companies, and that contractors are assured prior access to the calculation and information on revenues and expenses with assistance to their beneficiaries.

Abusive adjustments are challenged in court

Giselle Tapai, a lawyer specializing in consumer law with a focus on health, says that it is common for unjustified readjustments to occur by health plan operators, with obscure calculations and without further clarification, resulting in legal challenges.

“This type of lawsuit does not question the legality of the rules that regulate the readjustments in supplementary health, but the calculation of the readjustment”, he says.

By law, after the readjustment, consumers can request detailed information from the benefits administrator or operator, who have a maximum period of ten days to provide them, according to the ANS rule.

The lawyer recommends contacting the operator and requesting all the information that justifies the applied increases. “If there is no solution, the consumer should look for a lawyer to analyze his contract and verify if there was an excessive increase based on the history of payments.”

If there is irregularity, the lawsuit may be a way to cancel the abusive readjustment. “By analogy, the application of the readjustments limited by the ANS should be established, with the possibility of refunding the amounts unduly charged in the last three years”, explains the lawyer.

Lawyer Rafael Robba, specialist in the right to health at Vilhena Silva Advogados, says that in most cases operators have difficulty demonstrating how they arrived at the index applied in contracts before the Court.

“Consumers have the right to clear and adequate information about the services they are enjoying, but, in practice, what we see is that, most of the time, it is not possible to gain access when seeking more detailed information.”

Robba also points out that, in many cases, operators do not present the necessary documents, making consumers successful in their actions.

According to Gisele, the process lasts around one to two years, counting the resources. She says that, in this type of demand, it is common for the judge to determine the performance of an actuarial technical expertise to assess whether the readjustments were “without reason, random or unnecessary to maintain the contractual balance”.

“In many demands, the health plan operator is unable to gather all the necessary documentation for the expertise to be carried out, or even, the elements presented end up being insufficient to earn the applied percentage”, reports the specialist.

ANS readjustment ceiling does not apply to collective plans

Unlike individual and family plans, the ANS does not set a maximum readjustment percentage for collective plans, which is determined through negotiation between the parties – which does not mean that it can be done randomly or abusively.

Giselle explains that the calculation is made up of the financial adjustment, which considers medical inflation, and the accident adjustment, according to the use of contracted medical services.

“The financial readjustment, by itself, is already high enough, as the inflation of medical and hospital costs is much higher than the country’s average inflation”, says the specialist.

The readjustment for claims is calculated based on the amount collected with the payment of monthly fees during one year, from which the cost of medical services used by users is subtracted.

“In this type of modality, the readjustment is carried out based on free negotiation between the contracting parties, and the National Supplementary Health Agency is only responsible for monitoring these readjustments”, says Tapai.

In Brazil, there are 8.9 million individual or family health plans and 41.3 million collective ones. Among the collective plans, 35 million are business plans and 6.2 million are collective membership plans.

According to ANS, while contracts with 29 lives or less must follow a specific rule, those with 30 beneficiaries or more are negotiated without agency interference, between client and company, considering the use of the plan and the size of the portfolio.

The agency also says that, in addition to the annual readjustments of contracts, there may be readjustments due to age group changes. “It should be noted that the regulation of health plans protects the elderly, by preventing uncontrolled increases, especially for consumers who are in the last age groups.”

The ANS also states that it carries out technical monitoring visits to the operators, and one of the selection criteria for its sample is readjustments of collective agreements above what is practiced in the market.

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