Should health plans cover dengue testing? Understand – 02/17/2024 – Balance and Health

Amid dengue outbreaks that put the country on alert, it is natural to want to take a diagnostic test as soon as symptoms such as high fever, pain and red spots on the body appear.

For those who have health insurance, however, a series of bureaucracies seem to get in the way of the exam. Health law experts warn that only a medical prescription is required for authorization.

Understand below what the obligations of health plans are to policyholders when it comes to dengue testing.

Can the plan deny the test?

If there is a medical request, no.

The National Supplementary Health Agency (ANS) informs that rapid tests (IgG and IgM) for the disease, Elisa serology (IgG and IgM) and NS1 Antigen have mandatory coverage provided for in the List of Health Procedures and Events, all without usage guideline, that is, a doctor’s request is sufficient.

According to the agency, “denial of assistance coverage is not permitted under any circumstances”, since operators are obliged to offer beneficiaries all the procedures provided for in the contract and in the ANS list.

What is the deadline to take the test?

The guarantee period for dengue tests is three working days when requested electively (outpatient or office care). If it is an emergency, release must be immediate, still according to the ANS.

Bureaucracies such as needing to go in person to the health plan’s headquarters to have the test released or needing to wait for periods of up to ten days are considered abusive practices, says lawyer specializing in consumer law Arthur Rollo.

“[Isso é] to make it difficult. If you tell me, go to the headquarters to release it or pay here, I will pay”, says Rollo. “Many consumers on a daily basis will waste work, time, and end up paying”.

What should I do if my plan denied or made testing difficult?

This type of behavior can be reported to the ANS.

Lawyer specializing in health law Estela Tolezani, partner at the firm Vilhena Silva Advogados, says that many denial cases are not taken to court because the amount does not compensate for the process. But she reaffirms: health plans cannot deny any type of exam.

ANS is the main channel for receiving demands from health plan users and works through the Preliminary Intermediation Notification (NIP).

Through the NIP, the complaint registered in the agency’s service channels is automatically sent to the responsible operator, who has up to five working days to resolve the beneficiary’s problem in cases of non-guarantee of assistance coverage and up to ten working days in cases of demands non-assistance.

If the problem is not resolved by the NIP and a violation of sector legislation is found, administrative proceedings are initiated which may result in the imposition of sanctions on the operator, such as the imposition of a fine.

ANS service channels

Anyone experiencing service problems should initially contact their own health plan to resolve the issue and, if the issue is not resolved, they can file a complaint with the ANS. The service channels are:

• Electronic form at the Consumer Center
• Call center for the hearing impaired: 0800 021 2105
• ANS centers existing in the five regions of the country. Check out the units with in-person service here and make an appointment online.
• Dial ANS (0800 701 9656): free telephone service, from Monday to Friday, from 8am to 8pm, except national holidays.