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Amil follows prevented by Justice readjusting health plans

16/10/2013

This article was translated by an automatic translation system, and was therefore not reviewed by people.

 

 



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Operator , however, should only return what was overpaid retroactive to November 2011


IG


São Paulo - Amil suffered another defeat in court and follows prevented from increasing tuition plans health of micro and small businesses based on the degree of utilization of medical services , the so-called reset by accident . But the company only need to partially reimburse customers .

Amil Headquarters : The company spearheads legal battle over claims for adjustment
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The accident is one of three adjustment criteria used in collective plans ( those signed by companies or associations ) , which are the fastest growing in the country and already account for about 70% of the market.

The National Health Agency (ANS) sees no irregularity in practice , and even supported the Amil in the process . Consumer protection agencies and the courts , however , have questioned her claims by allowing significant increases - the case that led to the conviction of Amil , in 2012 , resulted in an adjustment of 1.000 % applied to a contract microempresária São Caetano do Sul ( Greater São Paulo ) .

Last week , the 6th Business Law Chamber of the Court of Justice of São Paulo ( TJ - SP ) refused a new appeal against the decision of Amil , 2012 . The decision, announced on Monday ( 14 ) requires the company to review the increases applied to all claims by adhesion contracts already signed with micro and small businesses across the country

The Judge Fortes Barbosa, rapporteur of the case , hinted that Amil should recalculate tuition and take into account only the two other criteria specified in the contracts : inflation and possible changes of age . The request was made by the Public Prosecutor of São Paulo ( SP - MP ) , which , in 2011 , filed a civil suit against the company after learning of the increase of 1,000 % .

contractual balance

The magistrate , however, understands that customers can only see back the amounts paid from November 24, 2011 - the date on which the action against Amil came to court - and not in any period . The adjustment of 1.000 % occurred in 2009 and 2010 .

The MP - SP questioned the limitation that had been defined by Barbosa July 2013, but the judge denied the appeal . For the judge , determining aims to " preserve certain equílirio the contract ."

Lawyer of the Brazilian Consumer Defense ( IDEC ) , Joana Cruz questions the decision, but argues that the criterion may be appropriate if , eventually , the value to be returned is too big for the company .

" Because this is a class action , will be a very large value . The operator has only to claims adjustment for balance , there are other ways . And even if you fail , it is a liability of the operator , "says the lawyer. " But it is better to receive little or nothing ? "

In a statement, Amil said that " it is the role of ANS to the public interest in the health supplement " and that " the possibility of adjustment based on risk ( accident ) is the essence of any contract securitarian nature , as a condition of maintain your balance, that balance is guaranteed by law and constitution . "

The prosecution said it has not yet learned of the decision .

legal battle

Both SP and MP - Amil must resort , which will lead to Brasilia a legal battle that matters the health insurance market as a whole. The case of Amil , besides involving the largest company in the sector , would be the first civil action on the subject to reach the Superior Court of Justice ( STJ ) . In an individual case , the court considered the increase in regular claims .

As health plans collective readjustment is not limited by the NSA , are common in cases where operators apply high rises based on the criterion of accidents . This usually occurs shortly after treatment of an employee, especially in small businesses .

Often , the adjustments are so high that eventually blocked by the courts . Survey by iG in 59 decisions on the subject in São Paulo showed that in 40 of them , the magistrates of the Court barred the increases - one of them 747 % . The cases involved 14 operators - four of them are among the ten largest in the Country

" After fault coverage , [ high adjustment ] is one of the major demands that we have ," says Joana Cruz .

This year , the NSA has changed the rules for group health plans with 30 lives , to prevent the increases are very high .
A survey released in July by Idec , however , identified increases of up to 43.25% among these plans .

 

 

Source: The Day - Online

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This article was translated by an automatic translation system, and was therefore not reviewed by people.

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