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Plano de saúde: O que fazer quando é negado a medicação ou tratamento?


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É muito frequente nos depararmos com a negativa do plano de saúde em fornecer certos tipos de medicamentos ou tratamentos para o paciente. Em muitos casos, as justificativas na impossibilidade do fornecimento são em razão de que não são devidos, pois não estão inclusos no rol de procedimentos disciplinados por alguma resolução normativa da Agência Nacional de Saúde (ANS). Quando ocorre casos de negativa por parte do convênio, o contratante, ora paciente, vê-se impossibilitado de usufruir daquilo que foi contratado, aumentando o risco à sua vida e fazendo com que seu tratamento ocorra em condições extremamente gravosas. Ao negar um procedimento, medicamento ou autorização para a realização de exame, o convênio fere a finalidade básica do contrato, colocando o usuário em posição de intensa desvantagem. Inclusive porque a lista de procedimentos da Agência Nacional de Saúde conta com apenas a cobertura mínima obrigatória, mostrando que até era um rol exemplificativo, motivo pelo qual deve ser conjugada com os princípios do Código de Defesa do Consumidor e da lei 9656/98.

Dessa forma, não cabe à operadora do plano de saúde negar cobertura/medicamento a exame destinado a completar o diagnóstico, cujo tratamento tem cobertura. Tal interpretação diversa, acabaria ainda por dar às seguradoras de planos de saúde o poder de questionar os métodos a serem empregados pelo médico para o tratamento da doença, cuja cobertura está abrangida pelo contrato. Mesmo que as empresas de planos de saúde privados possam estabelecer quais patologias não são cobertas pelo seguro e inserir tal previsão no instrumento contratual, a elas não cabe eleger os tipos de exames ou de tratamentos que lhes sejam mais convenientes.

O que mudou em 2022?

Em 08 de junho de 2022, o STJ – Superior Tribunal de Justiça, entendeu ser taxativo, em regra, o rol de procedimentos e eventos estabelecido pela Agência Nacional de Saúde (ANS), não estando as operadoras de saúde obrigadas a cobrirem tratamentos não previstos na lista. Contudo, o STJ fixou parâmetros para que, em situações excepcionais, os planos custeiem procedimentos não previstos na lista, a exemplo de terapias com recomendação médica, sem substituto terapêutico no rol, e que tenham comprovação de órgãos técnicos e aprovação de instituições que regulam o setor, isso não altera a interferência judicial para os casos que sem comprovem a necessidade de um tratamento ainda quem em fase experimental.

Importante ressaltar que a decisão do STJ não é vinculante, ou seja, os Juízes de primeiro grau e os desembargadores de segunda instância NÃO ESTÃO OBRIGADOS A SEGUIR ESTA ORIENTAÇÃO da corte superior, tendo livre convicção para decidir de forma diferente diante do caso concreto e das provas trazidas pelas partes no processo. Rol Taxativo: como proceder

Para ter a melhor obtenção de êxito da ação e do pedido liminar, é importante reunir provas que já apresentem a exceções criadas pelo novo posicionamento do STJ, em especial comprovar pelo relatório médico: que não há substituto terapêutico ou esgotados os procedimentos do rol da ANS, e que há necessidade do tratamento indicado pelo médico, além dos documentos relativos a todo tratamento já implementado, que não trouxeram resulto ao caso concreto.

Esteja atendo e procure associações ou advogados especializados e faça valer seus direitos.


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