February 6, 2023
Emergencies and Emergencies in Health Plans |  SEGS

Emergencies and Emergencies in Health Plans | SEGS

This time, care has been taken to examine and express my understanding regarding the suit granted before 2 Santa’s Civil Court CatherineFlorianópolis/SC, where the author recounted that he began experiencing abdominal pain five months after he contracted a health plan.

During his medical care for pre-operative examinations, he experienced sudden and severe pain.

He was diagnosed with acute cholecystitis, but the medical team refused due to the need for emergency surgery, but the plan refused to “cover” the procedure due to the lack of a contract. The amount charged by the hospital to which he was admitted did not reach 10,000 riyals.

When asked by the investigator from the above station, Walther’s doctor geartell him about the amazing and disastrous coincidence that the interviewee, commenting on this article, experienced about two years ago.

On that occasion I was admitted to the hospital, urgently, for cholangitis, which was also denied coverage on the simple claim of the health plan administrator and provider itself, that my contract would not provide for admission to the hospital closest to my place of residence.

It is worth noting here idiosyncrasy. It was interchangeable Email messages A staff member of the plan administrator repeatedly confirmed that the hospital he was in at the time was part of the contracting party’s authorized service network for this type of care.

Left in the hospital by my good Samaritan neighbor, I had no choice but to get into that hospital, mainly due to the fact that he was in the hospital. full pandemic Without any possibility of even looking for another hospital because there was no taxi or other means of transportation due to the late hour. By the way, not early as it was around 10:40pm.

Another peculiarity is that no care is provided for any type of deficiency required by health plans.

Given some similarities between the two cases, it is worth saying, Urgency and emergency And even his pathology, although there are different factual hypotheses with the Santa Catarina case and mine, both had a very high risk of death.

I will not bother my esteemed readers by focusing on the small differences between the two diseases. Only both are caused by inflammation of the gallbladder due to impaction of calculus in the cystic duct – cholecystitis; – and the other, cholangitis;when the calc goes into the common bile duct and causes inflammation.

My case is still in progress without judgment, perhaps on account of the sum paid by the columnist, marking nearly a hundred thousand reais, being dealt, in consequence, in a court of common law and not in a court of law. justice SpecialFormerly known as “small claims” court.

However, look at the case data and the identity of the operations: the lives of people who are in imminent danger, even though their health plans are duly paid for.

Returning to the subject of my speech and which I have decided to write, since everyone can freely access the information here, I want, at this point, to stick to what the judge of Santa Catarina has decided, Marcelo Carlin🇧🇷

In contesting the process that occurred in Santa Catarina StateThe operator claimed that the plaintiff’s contract is still within the grace period, that is, set at 180 days for clinical and surgical hospitalization, in addition to that coverage in urgent and emergency cases, during the grace period, was limited. up to 12 hours, in addition to related outpatient services.

In the well launched decision, the aforementioned judge understood that the dismissal thesis in light of the length of the contractual grace period did not merit admission.

In feeling – hence the word sentence – feelThe honorable judge noted that this requirement does not apply to emergencies and emergencies “as defined by the law providing for private health care plans and insurance. (Law No. 9.656/98).” Sentence excerpts🇧🇷

In addition, according to the aforementioned judge, the thesis that coverage in emergencies and emergencies will not be limited to 12 hours, because it would be inconsistent with the legal text and administrative rules, which in his opinion would not prevail.

Not providing the service. Urgency / emergencyhovering heavily under any premise.

First, because life has an invaluable value, it is enough to read and interpret Article 789 of the current Civil Code. Secondly, due to the fact that we take care of an enterprise that originated in a mount pew, ie very charitable. Thirdly, because no consideration is given to replacing a physical asset until it is insured under the insurance regulation that certain insurance companies can replace some parts used in car insurance. By the way, with this small digression, this type of insurance “did not take root” in the insurance market. four because The sixth clause of Article 12 of the Health Plans Law with wording Temporary Measure No. 2177-44 of 2001says that “there will be compensation, in all kinds of products and expenses incurred by the beneficiary with health care, in emergency or emergency situations, when it is not possible to use the special services, contracted, approved or indicated by the operators.. … ..etc.”

I think this is enough to motivate the high interest and good right that protects all users of health plans.

In conclusion, I will use an aphorism that I think is appropriate to add in this article, when Honore de BalzacHe judged him with extreme psychological prejudice: “Death is like a courtesan in her contempt, but the most faithful deceive no one.”

Thus, in these brief comments, I caution and highlight in plain English: health plan operators and managers, leave greed aside and be more concerned with the health and well-being of your members, who, after all, keep the managers involved. In order not to increase the indignation of its users.

that what I think.

Porto Alegre, 01/12/2022

Voltaire Marency – lawyer and professor