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Customers of health plans go to court to ensure the right to home care

07/15/2014

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

 

 

 


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Make it difficult companies offering the service and make beneficiaries to resort to the courts, where 90% of the decisions are favorable to consumidorRIO - Needing a care home can be a headache, often only resolved in court, due to the resistance of healthcare operators in provide the service. Specialists of the right to health alert about the system, which should be considered a continuation of the hospital started, changing only the local treatment of the patient. There are even understanding that any contractual clause excluding the service in the health plan is void. In Justice, in about 90% of cases consumers leave vitoriosos.O treatment is offered by health plan operators and their specificities are set in agreement with the consumer. Not always, however, such determinations are met. It happened with Apparecida Ricetto, 83, a resident of St. Paul. She had lost her speech and the right side of the body paralyzed after suffering a stroke in 2010. After a month of ICU, were two months of hospitalization. To make matters worse, she has Alzheimer's disease, hypertension, cardiac arrhythmia and diabetes.CONTA ARRIVES AR $ 25 MILApós discharge from the hospital, Stella Ricetto, niece of the elderly, has borne all expenses for surgical equipment, hospital bed rental , diapers, hygiene products, among other items, which reached U.S. $ 25 billion and should have been funded by plano.A family hired the service of Cemed care, Amil, but home care has a lot of headaches. Whenever needed an ambulance, needed to resort to Samu, public service, because the company was not available. For three months, she was left without home care because professionals were moved to other activities -. Unsure what to do in April recourse to a lawyer and went to court, demanding the implementation of the plan by which executive pay and that is not cheap. The injunction came out 15 days ago, and the company was required to provide the service, which now includes 24-hour nursing technician, nurse visit once a week to guide you and weekly doctor visit. They were also required to install a special bed, offering daily session of physiotherapy and medication - explains Stella.A lawyer Joana Cruz, the Brazilian Institute for Consumer Defense (IDEC), says that despite the strength of the companies, the good news is that the judiciary has pronounced mostly consumer-friendly manner. The Court of Justice of São Paulo, incidentally, Precedent 90 states that any provision is void exclusion of coverage of home service, when medically indicated: - I understand that this also applies to cases in which the company tries to limit the time provision of home care, which is also a form of exclusion. The service has to be provided by the time necessário.Sócia-founder of Lawyers Office Vilhena Silva, Renata Vilhena Silva, an expert on civil procedure and the right to health, says the average success in court is 88%. Renata says that although the processes arrive to transact for two years, since the sentence handed down an injunction requiring the provision of services in 48 out horas.Na assessment of attorney, in fact, home care is a profitable service to companies who only in 2013 recorded sales of $ 100 billion in Brazil. According to Renata, the justifications for denying care operators are not founded nor the economic point of view, since the cost of home care for a patient get to be 60% smaller than a hospital stay, did involve costs such as laundry feeding and some types of medicamentos.Dados health system reveal that in high-cost hospitals a hospital stay can rotate between £ 4000 and £ 5000 per day. At home, this low cost to £ 400 to £ 500, says Renata. The lawyer notes that many companies offering home care services also manage own hospitals for hospitalization of these pacientes.Caso clause which provides home care or any other contract is violated, the user must report the provider to the National Health Agency (ANS). The company will be notified and will have five to ten business days to resolve the situation - the time depends on the availability of healthcare risk for consumidor.Após this period, the beneficiary will be contacted by the NSA and asked whether the problem was solved or not. If not, a process in which the operator may be fined amounts ranging from £ 80,000 to £ 100,000 will open. Besides the fine, the plans with large numbers of complaints may be suspended for at least three months marketing. Since the beginning of the monitoring of the security service by ANS, 868 plans 113 operators had their sales suspensas.Também is important to note that if the carrier does not offer home care and there is an indication for domiciliary hospitalization, she should continue covering hospitalization. Among the 36,903 complaints made by consumers to the NSA of January 1 to May 31 this year, 202 (or 0.55%) had the word home care mentioned by the complainant. The provision of home care service is also subject to the provisions of Resolution 1.668/2003 the Federal Medical Council, which specifies the professionals who should compose the multidisciplinary teams of care to patients admitted to home scheme, besides the types of services that home care companies should dispor.O TELLING tHE EMPRESASSegundo the National Federation of Health Insurance (FenaSaúde), home care is not a mandatory coverage under the law and regulations of the ANS. To federation, granting the service is set to contract between the operator and the contractor plan or insurance health.The Amil also reinforces that home care with multidisciplinary care 24 hours is not a mandatory coverage. The service can be offered additionally as an alternative to hospitalization since met criteria as medical indication, clinical status, structural conditions of residence and family agreement. The costs of materials, medicines and care team, during treatment, are the responsibility of the case cited saúde.No plan, home care was authorized and funded by the service four times between 2010 and 2013. In all, the patient is framed-in needed to replace the hospital conditions. Finally, Amil points out that there are patients who, even requiring special home care, do not meet the criteria for adoption of home service care.Read more: http://oglobo.globo.com/economia/defesa-do-consumidor/clientes-de-planos-de-saude-recorrem-justica-para-garantir-direito-internacao-domiciliar-12866799#




Source: The Globe

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

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