Clipping of news on Brazilian Culture, Law and Citizenship
09.12.2015
This article was translated by an automatic translation system, and was therefore not reviewed by people.
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Design determines how unfair term to establish prior authorization as a condition of service
Senate Social Affairs Committee vote on Wednesday feiraFoto project: File / O Globo Agency
RIO - At a meeting on Wednesday, the Committee on Social Affairs (CAS) should vote on the Senate bill 480/2015, which typifies as a crime and considered an unfair contractual clause prior authorization requirement for the operator to perform admissions, consultations, tests or procedures covered by private plans of health care. The meeting is scheduled for 9 am, in room 9 Wing Senator Alexandre Costa.
The project, senator Marcelo Crivella (PRB-RJ) and whose rapporteur Senator Paulo Paim (PT-RS), also includes the Criminal Code (Decree Law 2,848 / 1940) Article 135-B, establishing the crime of health care conditioning, typified as follows: "demand, the representative, the employee, the manager or health plan operator manager or health care provider, the private health care beneficiary, the obtain prior authorization as a condition for holding any health care covered by the plan, including admissions, appointments, tests and procedures. " The proposed penalty for the offense is imprisonment from three months to one year and fine. If the denial of service results in aggravated battery or death, the penalty can be increased by half or tripled.
The project added provision to Article 16 of the Law on Health Insurance (9656/1998) to determine how abusive contractual clause establishing prior authorization as a condition for holding any health care, including hospitalizations, appointments, tests and procedures. The proposal also repeals device regulation that requires the plan or private insurance contract health care to establish clearly, among the conditions for its implementation, the identification of the acts, medical or charitable events and procedures that require administrative approval of operator.
Lawyer and researcher at the Brazilian Institute of Consumer Defense (Idec), Joana Cruz believes that if approved, the legislative proposal will do much to prevent abuses of the health insurance providers that often, instead of denying the procedure, simply let the consumer awaiting authorization indefinitely, causing him to give up the coverage by the operator and, in many cases, bearing procedure costs privately or using the NHS. "
Rafael Robba, lawyer specializing in office right to health Vilhena Silva Advogados, are looking to criminalize the conduct of the health plan to require the beneficiary to request prior authorization for procedures that are covered by the plan. In the lawyer's opinion, law text reinforces what the courts have understood for some time, as there -Set jurisprudence decisions that guide the interpretation of the judges - with the same understanding.
- The health plan can not interfere in the conduct of the doctor who is attending the patient and disallow a procedure that was requested by the specialist. On the other hand, it is necessary to reflect on one aspect of this legal text, if the plan does not have the prior control of procedures to be done, can increase the number of procedures performed unnecessarily. That would be a problem, since the plan may deny payment of procedure performed and the hospital may require the patient reimbursement of expenses - the expert adds.
FenaSaúde: purpose is not to disallow the doctor
The National Federation of Supplementary Health (FenaSaúde) points out that the previous analysis procedures such as hospitalizations and high complexity tests, aims to ensure the beneficiary as adequately meet local needs. The authorization process considers, among other factors, the clinical justification for the request, which must follow guidelines and approved clinical protocols for the various specialties and usage guidelines of the National SaúdeSuplementar Agency (ANS), for patient safety.
For complex procedures, the medical teams of health care providers verify that the prescription is in line with the best practices of medicine, it is not the case for a second opinion, if the requested material is appropriate and if there are other equally effective and less cost. It is important to check even if the patient is insured, is up with the monthly payments and no coverage for the defendant case.
"The purpose is not to disallow the doctor, but also protect the citizen and the system, which is maintained with funds from beneficiaries of plans and business employers that offer the product as a benefit," says FenaSaúde through his advice.
The rapporteur welcomes the adoption of the text, with amendments to improve the wording. If approved by the CAS, the proposal will be examined in terminative decision the Committee on Constitution, Justice and Citizenship (CCJ).
Source: The Globe
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This article was translated by an automatic translation system, and was therefore not reviewed by people.