See 7 rights of the elderly in health plans – 07/11/2023 – Market

The elderly represent more than 14% of the total beneficiaries of health plans in Brazil. In the last ten years, the number of clients aged 60 or over increased from 5.7 million to 7.2 million, according to a survey by the IESS (Institute for Supplementary Health Studies) with data from the ANS (sector regulatory agency). The growth is greater than the total number of beneficiaries, which registered a 1.9% increase in the period.

The age group is the most likely, in general, to undergo medical consultations, exams, therapies and hospitalizations and, therefore, has higher health costs in relation to other age groups.

The legislation guarantees these consumers specific rights and protections to ensure access to adequate and quality health care. The Statute of the Elderly determined that beneficiaries from 59 years old cannot have the value of the health plan readjusted by age (the so-called readjustment by age group).

To guarantee their rights, however, many elderly people have to go to court or to consumer protection bodies. Among the main demands, according to lawyers specializing in supplementary health, are those related to denial of coverage, delay in authorizing procedures, abusive readjustments and unilateral terminations.

Check out 7 rights of the elderly in the health plan

1 – Hire an individual plan

• Private health plans cannot deny elderly people adherence to their products. For Justice, the practice is considered abusive
• The Consumer Defense Code prohibits health insurance from directly refusing to provide services to anyone who is willing to acquire them.
• And the Health Plans Law expressly states that no one can be prevented from participating in private health care plans due to age or disability.

2 – Monthly plan fee without readjustment upon reaching 59 years of age

• The monthly fee for changing age groups is readjusted according to the change in the beneficiary’s age and can only be applied to authorized groups
• According to the ANS, it is foreseen because, in general, the more advanced the person’s age, the more necessary health care becomes and the more frequent the use of medical services.
• The rules are the same for individual, family and collective health plans
• The age groups for correction vary according to the date of contracting the plan and the percentages must be expressed in the contract
• The Statute for the Elderly prevents operators from adjusting prices by age group after their clients reach 59 years of age for contracts signed after 2004. The plan continues with permission to charge the annual adjustment, which for individual contracts has a maximum percentage defined by the ANS

The contract date	readjustment rule
Until January 2, 1999	Must follow what is written in the contract
Between January 2, 1999 and January 1, 2004	The price of the last range (70 years or more) may be a maximum of six times higher than the price of the initial range (0 to 17 years) Consumers aged 60 and over and who have been part of the contract for more than ten years cannot suffer the variation due to age group change
After January 1, 2004	The value set for the last age group (59 years or older) cannot be greater than six times the value for the first age group (0 to 18) The accumulated variation between the seventh and tenth bands cannot be greater than the accumulated variation between the first and seventh bands

3 – Having a companion at the hospital

• The Statute of the Elderly guarantees that patients over 60 years of age have the presence of a companion if they need to be hospitalized or remain under observation in a hospital
• The companion will have the right to food and priority service
• The companion is the patient’s free choice and must be between 18 and 60 years old

4 – Make the most of needs already met

• When leaving work, the elderly person has the right to change plans, taking advantage of the needs already fulfilled, provided that he respects the portability rules
• In cases where the user needs to change plans for reasons beyond his control, such as the death of the holder, cancellation of the contract or bankruptcy of the operator, price compatibility or compliance with the permanence period is not required.

5 – Keep the plan when you retire

• The retiree who paid part of the corporate health plan for more than ten years has the right to maintain the conditions of assistance coverage that he had during the term of his employment contract.
• In this case, he must pay the full amount of the plan; i.e. what already paid monthly plus the part that was the responsibility of the company
• Retirees who contributed to the health plan for less than ten years may remain in the plan for one year for each year of contribution.
• The retiree needs to be notified of this possibility and has 30 days to respond to the former employer.
• If not communicated by the former employer about the right, the retiree should contact the company’s human resources area and the plan operator to seek information about their rights.

6 – Assume ownership of the collective health plan by joining

• The elderly beneficiary who loses the status of dependent, due to being excluded at the request of the holder after more than ten years of contribution, has the right to assume ownership of the collective health plan by adhesion (contracted through unions and associations) , provided that it bears the respective cost
• The STJ (Superior Court of Justice) consolidated the understanding in October 2022, justifying that “the solution ensures health care for the elderly, without implying a change in the economic-financial balance of the contract”

7 – Have coverage during default of up to 60 days

• Termination of the contract by initiative of the plan without fair or apparent reason, such as the high loss ratio (costs with use) for a certain group, is an illegal practice
• Termination is authorized in cases of fraud or non-payment of the monthly fee, by the contracting party, for a period exceeding 60 days, consecutive or not, in the last 12 months of the contract term.

Sources: ANS (National Supplementary Health Agency), Statute for the Elderly, Law No. 9656, lawyer Giselle Tapai, Vilhena Silva Advogados and IESS (Institute of Supplementary Health Studies)