STJ DECIDES THAT ANS PROCEDURES ROLE IS TAXATIVE

ANS is an agency under a special regime, created by Law No. 9,961/2000, which has as one of its responsibilities the preparation of a list of procedures that must be paid for by health plan operators.

These procedures are mandatory coverage and must be provided by any type of health plan.

It turns out that there was discussion as to whether this list of procedures would be exemplary, that is, whether mandatory coverage for procedures not included in the list could be admitted, in order to guarantee the treatment prescribed to preserve the life or health of the insured, or whether the The list would be exhaustive, with coverage only of the procedures listed on the list being mandatory.

The 2nd Section of the Superior Court of Justice, seeking to pacify the issue, established the following thesis (EREsp 1.886.929 – Information 740):

1. The list of Procedures and Events in Supplementary Health is, as a rule, exhaustive;
2. The health plan or insurance provider is not obliged to pay for treatment not included in the ANS list if there is, to cure the patient, another efficient, effective and safe procedure already incorporated into the list;
3. It is possible to contract expanded coverage or negotiate a contractual amendment to cover an extra-role procedure;
4. If there is no therapeutic substitute or the procedures on the ANS list are exhausted, there may be, exceptionally, coverage of the treatment indicated by the attending physician or dentist, provided that (i) the incorporation of the procedure into the procedure has not been expressly rejected by the ANS. role of Supplementary Health; (ii) there is proof of the effectiveness of the treatment in light of evidence-based medicine; (iii) there are recommendations from renowned national (such as CONITEC and NATJUS) and foreign technical bodies; and (iv) when possible, interinstitutional dialogue between the magistrate and entities or people with technical expertise in the health area is carried out, including the Commission for Updating the list of Procedures and Events in Supplementary Health, without shifting the jurisdiction of the judgment of the case to the Federal Court, given the passive ad causa illegitimacy of the ANS.