Brazil’s Supreme Court Realigns Health plan Coverage Rules
Brasília, Brazil – September 17, 2025 – The brazilian Supreme Federal Court (STF) has reaffirmed a patient’s right to health plan coverage for medical procedures not explicitly listed by the National Health Agency (ANS), provided specific technical criteria are met and demonstrable evidence exists of denial or undue delay in authorization from the health insurer. the ruling, the result of resumed deliberations, establishes a significant precedent impacting millions of Brazilians reliant on private health insurance.
The decision clarifies a long-standing debate regarding the scope of mandatory health plan coverage. While the ANS maintains a defined list of covered procedures, the STF determined that health plans cannot automatically deny treatments absent from this roster if the procedures fulfill established technical requirements. Crucially, patients or their advocates must prove the health plan either refused the treatment outright or caused excessive delays in its approval. This ruling aims to balance the ANS’s regulatory role with individual patient needs and access to necessary medical care.
six justices – Cristiano Zanin,André mendonça,Nunes Marques,Luiz Fux,dias Toffoli,and Gilmar Mendes – sided with the interpretation favoring broader coverage. Conversely, Justices Flávio Dino, Edson Fachin, Alexandre de Moraes, and Cármen Lúcia argued the existing legal framework already encompasses exceptions not covered by health plans, and that the ANS should be the sole authority for defining technical criteria for off-list procedure authorizations.
The court’s decision underscores the constitutional right to health and seeks to prevent administrative hurdles from obstructing access to possibly life-saving treatments. The ruling is expected to prompt further clarification from the ANS regarding the specific technical criteria that will govern the authorization of non-listed procedures,and will likely lead to increased legal challenges as patients seek coverage for treatments currently denied by their health plans.
