June 14, 2024

Can the operator cancel my agreement?

4 min read
Individual health plans can be modified by more than 40%

Can a health plan cancel your contract at any time and leave you without health coverage? Experts heard before UOL Say that, depending on the type of health plan, cancellation can be made and it is not necessary to give a reason to the consumer.

There are two different rules for canceling a health plan by an operator: one that applies to individual and family plans and one that applies to group plans.

What is the rule of individuals and family members? Attorney Rafael Ropa, of Vilhena Silva Advogados, says operators can only cancel a consumer plan in the event of fraud or default.

The operator can cancel the plan of a consumer who has not paid the monthly fee for the plan for 60 days. In this case, the operator needs to notify the consumer until the fiftieth day of the delay to give the person the opportunity to repay the debt before the cancellation is made.

If he does not make the payment, the operator can cancel the plan. But it is important that the consumer is notified by the operator.

Cancellation can be made fraudulently when the operator discovers that the beneficiary has been doing something illegal, such as demanding reimbursement for amounts that were not paid in consultation or omitting an illness on the health statement when entering into the plan.

In any other circumstance, the plan cannot be canceled.

What is the cancellation rule for group plans? According to the law, operators can cancel group plan contracts without a specific reason – as long as such cancellation is provided for in the contract.

The consumer is usually notified 60 days in advance, but this is not a rule. The National Supplementary Health Agency (ANS) states that this minimum notice period must be in the contract.

It is these cancellations that reach the courts the most, Ruba says, especially when it is a patient undergoing treatment who will lose the plan.

Attorney Lucas Miglioli, partner at M3BS Advogados, says consumers should be aware when hiring a health plan. Usually group plans show the possibility of cancellation by the operator, he said.

Many people don’t know that an operator can cancel a contract without justification, Miglioli says.

For him, what is in the contract must be respected, and therefore, it is important that more and more companies have clear and objective contracts in a language understandable to anyone.

Can an operator cancel a single beneficiary plan from a collective agreement? According to the ANS (National Agency for Complementary Health), an operator can exclude only one beneficiary from the plan in the event of fraud or if they no longer work for the company or organization that contracted with the health plan.

Otherwise, the cancellation cannot be for one or a few people only, it must be for the entire contract. That is, it must include all beneficiaries served by this product. If it is a corporate plan, all registered consumers will be disqualified. The same goes for class associations.

Rupa says that if an operator decides to cancel the plan for only one beneficiary, the practice is considered “abusive and discriminatory.”

Can anyone go to court when the plan is scrapped? yes. What usually happens is that justice compels operators to keep the contracts of people undergoing medical treatment, even if the cancellation is stipulated in the contract.

Proceedings last an average of two years, according to Raba, but judges usually issue injunctions within three days to ensure the plan is not scrapped while the process is in court.

What treatments ensure continuity? There is no rule that defines the types of treatment for which the plan remains valid. Each case is analyzed by the judge. Ruba says that despite the cancellation stipulated in the contract, the judge understands it as abusive practice in intermittent treatment cases.

The ANS says that the operator needs to maintain inpatient care until discharge from the hospital. This also applies to actions that have been approved while the contract is in effect.

What do I do if my plan is cancelled? The first step is to try to negotiate a new contract with the operator or implement portability without any type of coverage limitation (allowing). Transfer period is up to 60 days from previous plan cancellation.

Portability has some rules defined by the ANS:

  • The current plan must have been contracted after January 1, 1999 or adapted to the Health Plans Act (Law No. 9.656/98)
  • The contract must be active, that is, the current plan cannot be canceled
  • Monthly payments cannot be delayed
  • The consumer must adhere to the minimum tenure period in the plan. In the first portability, the term in the original plan is two or three years if you have completed temporary partial coverage for a pre-existing illness or injury. In the second portability, the period of residence required is at least one or two years if you have made portability to the current plan with coverage not provided for in the previous plan
  • The target plan should be priced in line with your current plan

Rupa says that if the operator creates any barrier for consumers who meet the conditions of carriage, it is necessary to file a complaint with the ANS so that it finds out the reason for the refusal of the operator, and if it does not work, then seek justice. This is common for patients undergoing treatment and the elderly, Rupa says.

What to do if you were unlawfully excluded from the plan? The ANS states that the consumer should contact Dial ANS (0800701 9656), the call center for people with hearing impairment (0800 021 2105), the official website or ANS . cores existing in the country.

The agency says the operator can be fined up to R$80,000. If the ANS is unable to resolve the situation, the consumer is advised to seek justice.

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