Health Insurer Must Cover Emergencies Arising From Elective Plastic Surgery, Landmark Ruling Affirms
BRASILIA – A recent decision by Brazil’s Superior Court of Justice (STJ) mandates that health insurance plans are required to cover emergency medical care necessitated by complications from even elective, non-covered procedures like plastic surgery. The ruling establishes a critical precedent, clarifying insurer obligations when patients require immediate treatment to preserve their physical integrity following surgical procedures.
The case stemmed from a dispute were a patient sought coverage for complications arising during liposculpture and breast mastopexy, procedures not included in her health plan. Despite the initial surgeries being elective and private, the patient argued the healthcare operator should be responsible for covering subsequent emergency interventions.The STJ agreed, reinforcing that emergency care is of mandatory coverage, regardless of the original procedure’s status.
Minister Nancy Andrighi, Rapporteur of the recurso especial (special appeal), highlighted Article 35-C, item I, of Law 9,656/1998, which mandates compulsory emergency coverage for health plans. She further noted that Normative Resolution 465/2011 of the national Supplementary Health Agency (ANS) stipulates coverage for clinical and surgical complications, even those stemming from non-covered procedures, provided the required treatments are listed on the ANS roll.
“The obligation to fund the blood count and blood transfusion, performed due to complications during liposculpture surgery and prosthesis mastopexy, is not the patient, but the health plan operator,” Andrighi stated in her ruling. The court emphasized that the accreditation of the hospital where the surgery took place by the patient’s health insurance further solidifies the operator’s responsibility.
the decision, detailed in REsp 2.187.556, underscores the principle that health plans cannot deny emergency care based on the nature of the initial procedure, ensuring patients receive necessary treatment during critical situations.
