The Chamber of Deputies approved this Wednesday (3) a bill (PL) that establishes coverage hypotheses for health exams or treatments that are not included in the list of procedures and events of the National Supplementary Health Agency (ANS). The proposal goes to the Senate for consideration.
The article aims to continue treatments that could be excluded from the coverage of health plans. With the text approved, operators must authorize health plans to cover treatment or procedure prescribed by a doctor or dentist who is not on the ANS list, provided that one of the following criteria is present:
- there is evidence of efficacy, in the light of health sciences, based on scientific evidence and a therapeutic plan;
- there are recommendations by the National Commission for the Incorporation of Technologies in the SUS;
- there is a recommendation from at least one health technology assessment body that is internationally renowned, provided that they are also approved for their national counterparts.
STJ
The matter was approved after a decision by the Superior Court of Justice (STJ) that operators are not required to cover medical procedures that are not provided for in the ANS list. In the decision, the Court understood that the list of procedures defined by the agency is exhaustive, that is, users are not entitled to exams and treatments that are outside the list. https://agenciabrasil.ebc.com.br/justica/noticia/2022-06/stj-planos-nao-sao-obrigados-cobrir-condutas-fora-da-lista-da-ans
The ANS list of mandatory procedures and treatments was created in 1998 to establish a minimum coverage that could not be denied by health plans. The list has been updated since then to incorporate new technologies and advancements.
Since then, it is common for health plan users to seek in court the right of operators to pay for procedures or treatments that are not yet included in the ANS list.
The list of ANS procedures lists 3,368 health services, including consultations, exams, therapies and surgeries, in addition to medications and orthoses/prostheses linked to these procedures. These medical services must be offered in accordance with the health plan.
Discussion
The rapporteur, deputy Hiran Gonçalves (PP-RR), argued that the physician has the right to guide his clinical conduct based on his technical and ethical convictions about the positive impact of his decisions on the patient’s health. The parliamentarian also cited a survey by the Brazilian Medical Association (AMB) on the interference of health plans in medical activity, in which 53% of respondents reported interference from medical insurance companies in the treatments proposed to patients.
“A few years ago, in a judgment that also referred to Supplementary Health, the noble minister Carmen Lúcia, of the Federal Supreme Court, stated: ‘health is not merchandise; life is not business; dignity is not profit’. This wise and sensitive judge showed, in a nutshell, that the protection of the consumer’s right to health must override any less noble interests”, said the deputy.
Contrary to the measure, Deputy Tiago Mitraud (Novo-MG) said that the change will harm competition and increase the prices of health plans.
“It will be much more expensive and complex to have health insurance, and the small ones will go broke. The big pharmaceutical companies can now induce doctors to prescribe experimental treatments without approval by Anvisa”, he warned.
* With information from the Chamber Agency
