I ordered a health plan to pay for a patient saints, on the coast of Sao Paulo, who had to undergo surgery to remove skin cancer in a private clinic. According to the lawsuit, the plan asked the patient to perform the surgery by special means, believing that it would compensate her. After the procedure, the plan paid only R$2,000, out of the total R$6,700 that the woman had spent.
According to the sentence, the health fund will have a duty to provide the care recommended by the doctors who have evaluated the patient’s condition, and to cover her entire expenses. The decision was made based on the precedent 102 of the Court of Justice of São Paulo (TJSP), which states that if there is an express medical indication, the lack of funding for treatment is arbitrary and negative.
In addition, Articles 4, Clause 1, and 47 of the Consumer Protection Act are also referred to in order to reinforce the need for reimbursement.
- art. 4: The National Consumer Relations Policy aims to meet the needs of consumers, respect their dignity, health and safety, protect their economic interests, and improve their quality of life, as well as transparency and harmony in consumer relations, in accordance with the following principles:
- I – Recognizing the weakness of the consumer in the consumer market (…)
- art. 47: The terms of the contract will be better interpreted to the consumer.
The patient filed an application in court to pay the difference of 4.7 thousand Brazilian reais, in addition to the amount of moral damages. The health plan pointed out that there is no contract signed with the patient, so the amount of moral damages may not be paid.
At the end of the process, in March 2022, the judge in charge of the trial recognized the patient’s request as valid, and set the compensation at R$5,000 in her favour. The value, according to the judge, will be reasonable, given the circumstances.
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