The Superior Court of Justice (STJ) ruled today (8) that health plan operators are not required to cover medical procedures that are not included in the list of the National Health Agency (ANS). There is an appeal against the decision.
The Second Section of the STJ 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.
By 6 votes to 3, the understanding of the rapporteur, Minister Luís Felipe Salomão, whose vote was given in previous sessions, prevailed.
When defining that the list is exhaustive, the minister understood that there would be an imbalance in health plan contracts if some users obtained in court the right to coverage that others do not have. This would affect the economic balance of the complementary health system and increase costs for all users, according to the minister.
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.