Brazilian Health Plans Not Obligated to Cover Medical Exams Performed Abroad, Supreme Court Rules
BRASÍLIA – Brazil‘s Superior Court of Justice (STJ) has ruled that health insurance plans are not required to cover medical procedures – even those unavailable domestically - if performed outside of Brazil, unless specifically stipulated in the insurance contract. The decision, stemming from a case involving genetic testing unavailable in Brazil, reinforces the legal interpretation that health plan coverage is limited to the national territory.
The case centered on a patient seeking coverage for a genetic exam performed abroad. While acknowledging the exam’s absence within Brazil and arguments against restricting medical autonomy, lower courts initially sided with the patient. However, the STJ overturned those decisions, citing Article 10 of Law 9.656/1998, wich restricts coverage to procedures within Brazil except when expressly provided for in the contract.
Minister Nancy Andrighi, the rapporteur of the appeal, emphasized that the law “imposes on health plans the obligation to pay the procedures performed exclusively in Brazil.” She further clarified that interpreting relevant regulations confirms the area of coverage for health plans is “restricted to the national territory.”
This ruling aligns with previous STJ judgments, including REsp 1.762.313 and REsp 2,167,934,which previously denied coverage for international procedures and the mammaprint genetic tumor test,respectively,due to their performance outside of Brazil.
The STJ partially granted the appeal, deeming the action unfounded and stating that “except if there is a provision in a contractual clause, the legislator expressly excluded from the operator the obligation to guarantee the coverage of treatments or procedures performed abroad.”
Read the full decision here – REsp 2.197.919.
