TJ/SP Overrules Prior Rulings on Health Plan coverage
São Paulo, SP – The Special Body of the São Paulo State Court of Justice (TJ/SP) revoked precedents 100 and 102 on Wednesday, October 10, impacting rulings related to health plan contracts and coverage. The decision followed a request from Judge Heraldo de Oliveira Silva, president of the Private Law Section, after divergences were identified between the TJ/SP’s statements and consolidated guidance from the superior Court of Justice (STJ).
Precedent 100 had established that health plan and insurance contracts were subject to the rules of the Consumer Defense Code (CDC) and Law 9.656/98, even if the contract was signed before these laws came into effect. Specifically, the precedent stated: “The Health Plan/Insurance contract shall submit to the dictates of the CDC and Law 9.656/98 even if the agreement was celebrated before the validity of these legal diplomas.”
Precedent 102 previously resolute that denying coverage for medically indicated treatments based solely on their experimental nature or absence from the National Health Agency (ANS) list was considered abusive.It stated: “If there is 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 mandatory coverage of experimental treatments are no longer binding within the TJ/SP.
