Health plan, coverage is denied the biggest complaint
This article was translated by an automatic translation system, and was therefore not reviewed by people.
Carolina Dallolio
Refusal to allow the operator procedure takes
the top rank of complaints received by the NSA
More than half of complaints against health plans is made by beneficiaries who receive a negative response to the request to carry out any medical procedures, informs the National Agency for Supplementary Health (ANS). In the latest survey by the Agency for the month of June, the trend has been confirmed. The so-called "negative coverage" once again took the top consumer complaints, followed by problems such as increased tuition and abusive misuse of the network accreditation.
Are cases such as the mother of the systems analyst Geovane Rezende. After two hip surgeries, Maria Aparecida Rezende, 71, was left with severe pain in the column. To make an accurate diagnosis and prescribe treatment, the doctor requested an MRI. But the operator Samcil not authorized. "They argued that she had done a CT scan," says the son.
Rezende had to complain, file a complaint with the NSA and even send letters to the newspapers to, finally, received authorization for the exam. It took almost a month.
In an attempt to prevent cases like Rezende recur, the NSA has adopted a program that provides the reconciliation between beneficiaries and companies. When the client registers a complaint about denial of coverage on a channel service of the NSA, the agency will immediately trigger the operator asking her to reverse her decision.
"We have a direct channel of communication with operators, which is used to quickly resolve such conflicts," says Dalton Callado, associate director of the NSA surveillance. The service can be completed in a week, if the operator is willing to cooperate. "The idea is that the agency acts as a mediator of the case, trying to solve the problem without having to open a proceeding to adjudicate the matter."
In 2006, when the NSA had not established this communication channel, the claims will be automatically transformed in processes - carrying no less than 482 days on average to be analyzed.
Today, in most cases, it is necessary to open a case. The case is resolved by conciliation. But when a process needs to be open, although still extensive, the period of analysis has decreased: it was reduced to 146 days. "How many times can resolve the problem only with the mediation, today we generate fewer lawsuits and so could get a little more agile," said Callado.
Therefore, the recommendation is that consumers seek the NSA when faced difficulties in attendance. "The agency has become more efficient in solving these cases," says Celma do Amaral, assistant director of Procon-SP. "The only problem is that the NSA works well for individual cases, but does not use the information you have to act more broadly, instead of trying to change the behavior of operators who insist on making the same mistakes," he says.
Celma just underscores that while the NSA is now more efficient in these cases, it sometimes fails to stick to the legislation of the sector and does not consider aspects of the Code of Consumer Protection. This ends up with the agency denies the request for some beneficiaries, particularly those with contracts prior to 1999, when the terms of coverage were not as clear as today. "So even in cases where the NSA says that the carrier was entitled to refuse the application, the consumer should not give up," said Celma, recommending that the search Procon. The National Federation of Health had no immediate comment.
WHAT TO DO to be answered
IN CASE OF EMERGENCY
If the operator refuses to cover a medical procedure brings risk to the patient, the family should go directly to court. The judge may issue an injunction, allowing the execution of the procedure, only to judge whether the claim is justified or not
WHAT CAN YOU EXPECT
If the procedure is not urgent, then the consumer should read your contract and demand their rights. The company should be the first to receive the complaint
NO SERVICE
If the operator will take long to respond or refuses to authorize the procedure, the consumer must register the complaint ANS, by phone (0800 701 9656) or internet (in www.ans.gov.br). The agency will seek a quick solution to the case
OTHER CHANNELS
Complaining in court (www.procon.sp.gov.br), is also an alternative. Even if you have registered your complaint with the NSA, there is no reason to resort to that entity in parallel. The advantage here is not the time to serve, but the type of analysis performed by Procon: it is not limited only to the terms of the contract or the legislation of the sector, but also with the Code of Consumer Protection
Source: Jornal da Tarde
This article was translated by an automatic translation system, and was therefore not reviewed by people.
Important:
The JurisWay site does not interfere in the work provided by doctrine, why only reflect the opinions, ideas and concepts of their authors.
