A health plan has been ordered to compensate a client with more than R$13,000 for a client who requested hospitalization due to complications from Covid-19. The company’s refusal resulted in the patient paying hospital expenses Guarujaon the coast of São Paulo, and is part of the network approved for the Convention.
Judge Alexandre das Neves, of the Guaruja Special Civil Court, dismissed the suit, but defense attorney Geraldo de Souza Suprinho appealed the decision, which was partly accepted by judges of the fifth civil class in Guaruja state. saints Court of Justice of São Paulo (TJ-SP).
In July of last year, the client was admitted to the Casa de Saúde Hospital in Guarujá. According to the judges’ decision, in the attendance form and in the admission record there is information that the hospitalization was carried out through health insurance, which was confirmed by the hospital.
According to the ruling, the plan was to transport the patient because the cost of the hospital in Guaruja would be higher than the cost of the approved hospital also in Santos, a neighboring city.
The text also confirms that the service provision contract between the agreement and the hospital is not visible to the beneficiaries.
One of the clauses includes coverage for “General Hospital” and “clinical and surgical arrests,” therefore, Rapporteur Dario Gayoso Jr. indicated that, contrary to what the plan maintained, the hospital in Guaruja belonged to the approved network, and therefore, treatment costs should have been covered by insurance in the hospital.
Since the plan refused to enter the hospital, forcing the client to pay directly to the hospital, the reporter mentioned that it is not just compensation for the appropriate use of the plan, but compensation, which fully returns the amount spent by the client, with the additions of cash correction from the exchange and interest on late payment by 1% per month, counted until payment.
The rapporteur added that, on the other hand, no compensable moral damage is expected because the medical care was carried out without any risk to the client’s health.
In a note, NotreDame Intermédica stated that when he needed medical attention, the patient went to Casa de Saúde Guarujá Hospital, where he received all the necessary emergency care authorized by the plan.
“In this case, the unit was not part of the optional hospitalization network to cover your plan. Because of this, the company made it possible for you to go to another hospital immediately, with hospitalization covered for your plan,” the company says.
The plan also emphasizes that the beneficiary “chose not to accept.” [a mudança] And he decided to private hospitalization in the hospital where he was.”
“In the first instance, the judge stated that he was not in a state of emergency and that, despite the alternative, he freely opted for private care, and gave the operator the right. In the second, the judge gave the beneficiary the right to reimburse, while maintaining the understanding as to the absence of moral damage. ‘, he concludes.
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