TJ/SP Overrules Priorโฃ Rulings on Health Plan coverage
Sรฃo Paulo, SP – The Special Body of the Sรฃo Paulo โState Court of โJustice (TJ/SP) revoked precedents 100 and 102โฃ on Wednesday, October 10, impacting rulings related to health planโ contracts and coverage.โค The decision followed a request from Judge Heraldo de Oliveira Silva, president of theโค Private Law Section, after divergences were identified between the TJ/SP’s statements and consolidated guidance from the superior Court of Justiceโค (STJ).
Precedent 100 had established that health plan and insurance โขcontracts were subject to the rules of the โConsumer Defense Code (CDC) and Law 9.656/98, even if โ the contract was signed before these laws came into โขeffect. Specifically, the precedent stated: “The Health Plan/Insurance contractโข shall โคsubmit to the dictates of the CDC โand Law 9.656/98 even if the agreement โwas โฃcelebrated before the validity โฃof โขthese legal diplomas.”
Precedent 102 previously resolute that denying coverage for โmedically indicated treatments based solely on their experimental nature or absence from the National Health Agency (ANS) list was considered abusive.It stated: “If there โis a medical indication, the negative treatment of treatment costs on the grounds of its experimental nature is abusive or for not being provided for in the ANS procedures list.”
With this revocation, these prior understandings regarding the retroactive request of the CDC and mandatoryโ coverage of experimental treatmentsโ are no longer binding within the TJ/SP.
