TJ-SP creates reconciliation center between plans and users – 12/03/2023 – Balance and Health

Faced with the increase in lawsuits against health plans, the TJ-SP (São Paulo Court of Justice) launched a new conciliation program between operators and customers. The initiative seeks to encourage agreements to close ongoing processes and avoid the opening of new litigation.

“Every 25 minutes, the São Paulo judiciary receives a new action against a health plan”, says judge Maria Lúcia Pizzotti, coordinator of the court’s Nupemec (Permanent Mediation Center) and responsible for coordinating the project.

Denial of healthcare coverage, abusive adjustments and refusals of requests for medicines or surgeries are among the main reasons for disputes in court. According to the judge, in 90% of cases companies are defeated at the end of the process.

“It’s a long, expensive process that usually requires medical expertise, so everything becomes very complicated. This comes with a very high cost for health insurance companies and a lack of response for the consumer, because while the process is being processed, there is no answer and sometimes they are emergency procedures”, says Pizzotti.

Conciliation can be requested by both customers and companies through a platform on the TJ-SP website. Next, the judiciary’s conflict resolution sector will schedule a virtual session with the presence of a mediator specialized in health cases. Nupemec has received 17 requests to schedule sessions since the program launched on November 16th.

Data from the TJ-SP indicate an increase in judicialization against supplementary healthcare providers. From January to October 2023, the São Paulo judiciary received 18,628 new lawsuits, a number that exceeds the volume registered in the same period last year by 17%.

For Pizzotti, the increase in judicialization is a reflection of the law that made coverage of treatments outside the list of the ANS (National Supplementary Health Agency) mandatory. Sanctioned in September last year, the legislation defined that the list of procedures is not exhaustive, and serves only as a reference.

The assessment is shared by lawyer José Luiz Toro da Silva, vice-president of the Medical and Health Law Commission of the OAB-SP (Brazilian Bar Association), who foresees an even greater impact of the measure in the future.

“Until then, we had a way of calculating the price of the health plan, because we knew what would be covered. Now, with the list being an example, one of the consequences is the increasing increase in the price of health plans”, he states Toro, who works as a legal consultant for Unidas (National Union of Self-Management Institutions in Health), an entity that represents non-profit plans.

When contacted, Fenasaúde (National Supplementary Health Federation), representative of the country’s main health plans, states that it considers mediation an effective instrument for resolving and preventing disputes. According to the TJ-SP, the conciliation rate for ongoing actions is 28%, and reaches 75% when the agreement occurs in the pre-procedural phase.

The organization also emphasizes that “adhesion to initiatives of this nature is free for operators, depending on their operational particularities and internal processes”. The court has already received the registration of 43 companies.

“The entity also highlights that all of its associates offer customer service and ombudsman channels for clarifications, answers to doubts, negotiations and the search for a prompt solution to various cases, without the need to call the Judiciary. Furthermore, it highlights the effectiveness of the mediation process of the National Supplementary Health Agency (ANS), with resolution rates above 90%”, he concludes, in a note.

Abramge (Brazilian Association of Health Plans), in turn, points out that its members support conciliation initiatives, as well as all conflict resolution alternatives, but that companies are still analyzing adherence to the TJ-SP program.