May 26, 2024

The Catholic Transcript

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Urgent delivery costs must be paid by a health plan without obstetric coverage

Covering emergency obstetric care is mandatory, even if the contracted health plan is a fraction without obstetric coverage.

The Health Plans Act establishes an obligation to pay for urgent care

The third panel of the Supreme Court of Justice applied this understanding by rejecting the special appeal submitted by the HMO against a conviction for moral damages for refusing to care for a pregnant woman about to give birth.

In this case, the woman went to an agreed-upon hospital, and during labour, she was informed that she would need emergency hospitalization because the baby was in fetal distress. However, the health plan will not cover the procedure.

The hospital did not attend the pregnant woman and advised her to run out of time for some other units. Thus, the woman called for an ambulance and was taken to a public hospital, where the emergency was confirmed. The birth has taken place and the newborn needs resuscitation.

Both the health plan and the hospital were convicted by normal cases of compensating the woman for a final, arbitrated sum of R$10,000 each.

STJ health plan argued that maternity coverage could not be ordered because the contract signed with the beneficiary was to divide the hospital without obstetric coverage, which the health plans law allows in full (Law No. 9.656 / 1998).

Rapporteur Minister Nancy Andregue noted that the National Supplementary Health Agency (ANS) Act and Rules – in Normative Decision No. 25/2012 – allow segmentation of services in the sale of health plans.

On the other hand, Section 35-c, Clause 2, states that health plans are obligated to cover emergency care, including complications in the pregnancy process.

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Minister Nancy’s vote cites supplemental health board rules, the ANS and STJ’s case law, which indicate that urgent and emergency coverage is not limited to just what was spent in the first 12 hours of treatment.

She added, “Therefore, the fact that the beneficiary’s health plan is divided into hospitals without childbirth does not change the duty to cover emergency care resulting from complications of the pregnancy process, as it is, as we have seen, a mandatory coverage case.”

The vote came in the third session unanimously, according to Minister Nancy Andregui’s position. She was accompanied by Ministers Ricardo Villas Boas Cueva, Marco Aurelio Bellese and Maura Ribeiro. Judge Paolo di Tarso Sanseverino was not justifiably involved.

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