Camila Vieira Guimarães
Lawyer at Marcos Martins Advogados
A beneficiary who was denied an emergency procedure by his health insurance provider, even though it was provided for in the contract, was ordered by the court to reimburse the full amount spent out of pocket.
On appeal, the operator requested that reimbursement be limited to the price it charged for the procedure, taking into account its own accredited table and not the amounts charged by the hospital where the procedure was carried out.
The Reporting Justice of the 3rd Panel of the Superior Court of Justice, Nancy Andrighi, ruled in Special Appeal No. 1.840.515 – CE (2019/0290481-8) that, although the use by the beneficiary of a health plan of a procedure outside the accredited network that is subject to reimbursement is an exception, as case law has held, there was an undue denial of the contractual provision by the plan operator and the urgency of the procedure.
It also held that the reimbursement should be for the amount actually spent by the beneficiary, and that it is unacceptable for the beneficiary to bear any loss arising from the breach of contract by the health insurance provider.
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