Health plan ban complaints skyrocket in two years in Bahia

Finding a doctor you trust creates a relationship of loyalty. And not being able to consult this professional anymore because the health plan has decided to ban his studio or clinic where he works becomes a big problem. In Bahia, in the last two years, the number of complaints against health workers for disqualification has grown by 46%, according to data from the National Agency for Integrative Health (ANS).
From 1 January to 29 November 2020 there were 45 complaints against 66 in the same period this year. In 2021 the number had already grown, with 50 complaints. In all, 1,660,703 people have an individual or collective plan in the state.

Teacher Lúcia de Fátima, 53, faced the situation when she tried to make an appointment with a low vision specialist for her youngest daughter, who is visually impaired, and received information that the clinic was no longer provided by Unimed Nacional . “It’s a desperate situation because my youngest needs follow-up and not all ophthalmologists understand her condition,” she laments.

Lúcia says she even called the operator looking for another specialist doctor in the area, but was unable to find one in Bahia. She and her daughter made an appointment with the attending physician and subsequently requested reimbursement. Of the 300 BRL charged for the service, the plan returned only 81 BRL.

The changes in the network of service providers are due to an attempt to reduce costs by companies, explains health lawyer Rodrigo Araújo. “Complaints have increased across the country. SulAmérica has excluded in the individual contracts all the laboratories that are not part of Rede Dasa. He informed in advance, but only communicated that he continues to have service ”, he exemplifies. “The consumer took, for example, 20 lab brands and now has 10, but still pays the same amount,” he says.

The way in which the interdiction takes place varies according to the behavior of the company. “Amil has been doing it for a long time, she has episodes of hospital disqualification in the current old floors that she no longer sells. Unimed has a lot of scaling of the accredited network (reorganize the size) ”, he adds.

hospitals

There are also complaints about the interdiction of the hospital network, but in smaller numbers. ANS received 101 between January and November 2020, 63 in the same period in 2021 and 46 in 2022. In this case there is a drop of 54%.

Attorney Rodrigo Araújo warns that for hospitalized patients, disqualification can only occur when there is a definitive discharge. But if it is a question of continuous care without hospitalization, such as chemotherapy, it is necessary to appeal to the Judiciary. In other cases, the termination is valid according to the announcement, whose notice must be issued up to 30 days before the exclusion.

The Vice President of the Association of Insured Health Plans of Bahia (ASPS-BA), Leonardo Miranda, receives between 2 and 3 complaints a day. In November, the companies with the most complaints were Unimed Norte/Nordeste (29), Hapvida (23), SulAmérica (21), Bradesco Saúde (18) and Amil (10).

ASPS-BA analyzes the cases and follows those in which it believes there are abuses free of charge. You can get in touch through social networks (@asps.ba) and telephone (71 99734-4397).

justice case
However, the law governing private health insurance allows forfeiture only if replaced by another equivalent. The operator must notify the beneficiaries through the website and the Call Center at least 30 days in advance. The determination affects non-hospital network providers, such as clinics and laboratories.

ANS advises users to initially look for the operator to solve the problem and, if there is no solution, to file a complaint through one of its service channels. Experts still recommend that the consumer keep the contract and documents proving the network initially offered by the plan.

In the event of failure to resolve, the lawyer specialized in health law Marina Basile recommends that the beneficiary contact the Judiciary. She herself has already had problems with the SulAmérica plan and hopes that the judge will determine the extension of the network, placing new providers and moral damages. “I lived it and my whole family. They changed laboratories from time to time because of the operator himself, ”she says. She and her mother, Analiz Goes, 75, are seeking non-pecuniary damages in court over the unannounced disqualification of new suppliers.

The National Federation of Complementary Health (FenaSaúde), which represents 14 groups of plan operators, informed that negotiations between service providers and operators take place individually and that it is up to the companies to organize networks that meet the needs of the beneficiaries.

The report reached out to the National Association of Private Hospitals (ANAHP) to find out how private healthcare facilities were affected by the suspension, but received no response until this issue closed. Unimed, Hapvida, SulAmérica, Bradesco and Amil have not sent individual positions.

Patients with high-cost treatment are most affected
Healthcare law specialists say patients who require more medical care, such as the elderly and people with expensive care, are the hardest hit by the interdict policy.

According to lawyer Rodrigo Araújo, the areas generally excluded from a hospital’s network are oncology, neurology, orthopedics and cardiology, due to the cost of treatment. “When the establishment is disqualified, the entire public suffers indiscriminately. However, if only some areas are left out, only patients who have problems related to those areas are affected,” says Araújo.

Lawyer Marina Basile, on the other hand, cites the elderly as another public suffering from neglect, as they need many specialties and services are already expensive even in the most basic plans. “More and more people perceive an increase in the disqualification demand for services that used to be offered for consumption or disqualification and does not place the supplier in place or disqualification and does not place suppliers in the same technical quality as they once were.”

*With guidance from Chief Reporting Officer Perla Ribeiro.