When an insured individual chooses to take up a well being plan with nationwide coverage, the expectation is that he may be seen by any contracted physician, impartial of his place of residence and employment.
Many sufferers of the completely different UNIMEDs that exist in Brazil discover themselves in difficult conditions once they want to search medical professionals from different cities or states than their authentic sufferers. For these sufferers, who often dwell in city facilities with a scarcity of specialised medical professionals, they’ve to resort to different bigger city facilities the place care is extra on provide.
In such circumstances, it’s usually alleged that coverage can’t be assured, as these professionals from different states don’t have a contract with UNIMED of the insured individual’s origin, making it inconceivable to present the required coverage.
However, the judiciary has, in these circumstances, utilized the precept of look, to perceive that well being insurers belonging to the identical title might be organized as a part of the identical financial group/conglomerate, and even when they don’t share a CNPJ (authorized persona), or whose geographical Aadhaar is completely different, having agreements guaranteeing mutual coverage of their policyholders. And, due to this, any conduct that goals to stop entry to medical service solely confuses the insured individual and postpones the achievement of the contractual obligation.
And, with that, the insured one that has a nationwide coverage plan, and who wants to resort to medical professionals in a geographical space apart from the unique considered one of his contract, has the precise to be assured full coverage, as in his pure space. have been:
Civil enchantment – Action on legal responsibility to compensate for ethical damages – Health scheme – Early govt withdrawal due to absence of storage of preparation – Acceptance – Appeal of Consolidated Nordeste Limited not recognized – Preliminary illegality inactive – Denial – Denial – Denial – Coverage of drug Rituximab (Mabthera) 375 mg – Insurance (Supply of Medicines for Home Use) with Autoimmune Diseases (Antiphospholipid Antibody Syndromes and Lupus) – Requirements Not Met – Moral Damages Absent – Reversal of Contingent Burden – Reversed Judgment – Appeal Unanimously Allowed.
(…) 2. Initial passive illegality: the legality of the events, energetic or passive, it can be crucial to notice that solely the precise holder can focus on it or defend himself in courtroom, and the opposite events
Demand needs to be one other topic of equal rights. According to the precept of look, verifying that authorized entities belong to the identical financial group, even when their authorized persona and geographical base are completely different, the Single Court should acknowledge the legitimacy of composing the passive pole of the dispute. Therefore, Unimed Recife has the legitimacy to seem on the defendant’s facet of the declare. Initial rejection. ??
(TJPE, AC 0022386-24.2019.8.17.2810, fifth Civil Chamber, Judge Agener Ferreira de Lima Filho, Judge on 12/20/2022)
Civil and Consumer Procedural Law. illegitimacy. Rejected. well being plan. Liability for medical and hospital coverage. Assistant Physician’s Prescription. Transester within the autism spectrum. Multiple therapies. Appeal granted.
1. Unimed Recife has passive legitimacy to seem within the go well with as a result of it’s related to different cooperatives that make up the Unimed financial group, in addition to the speculation of look applies, as a result of the cooperatives use the identical identification, placing themselves first. The shopper as an financial group and collective act. ??
(TJPE, AI 0002504-62.2021.8.17.9000, 1st Civil Chamber, Reporting Judge
Frederico Ricardo de Almeida Neves, decide on 11/19/2022).
Civil enchantment. well being plan. Initial passive illegality rejected. Antineoplastic medicine. Unreasonable delay. ANS Resolution 259. Configurable Moral Damages. saved quantum.
1. Unimed Recife has passive legitimacy to seem within the go well with as a result of it’s related to different cooperatives that make up the Unimed financial group, in addition to the speculation of look applies, as a result of the cooperatives use the identical identification, placing themselves first. The shopper as an financial group and collective act.
2. It is the duty of the well being scheme operator to promptly reply to the coverage supplied in pressing and emergency conditions, in accordance to Art. third, Inc. XIV of ANS Resolution No. 259/2011.
3. The well being plan operator’s delay in authorizing coated and vital procedures for the therapy of the insured individual prompted real psychological anguish to the insured individual, elevated compensation for ethical damages, because it interfered together with his well-being, prompted insecurity, psychological misery. , contemplating his already fragile scenario, as a results of the sickness affecting him.
4. In the scenario now beneath evaluation, the arbitration of the compensation quantity of BRL 15,000.00 (fifteen thousand reais) decided by the decrease courtroom was no more than affordable, contemplating the twin goal of the compensation: as compensation for serving and as a deterrent to unlawful apply by punishment.
(TJPE, Civil Appeal 412969-30086709-02.2014.8.17.0001, Judge Jose Fernandez de Lemos, fifth Civil Chamber, Judge on 05/19/2021, DJe 06/15/2021)
In the current case, the scenario was analyzed above. A affected person dwelling in João Pessoa/PB and insured in Unimed João Pessoa had to go to a medical skilled in Recife/PE to affirm his prognosis of superior stage prostate most cancers. However, when his well being plan sought the surgical procedure beneficial within the medical report, he was denied on the grounds that he wouldn’t use the insured community, and that the process was not coated by the contract.
While looking for justice, the affected person confronted denial by the courtroom of first occasion, which agreed with the thesis that “it could be coverage exterior the acknowledged community”.
This led the affected person to enchantment to the Court of Justice of Pernambuco, which, additionally in forensic recess, granted the injunction sought, ruling that the plan assured full coverage of the therapy prescribed by the physician, primarily based on the doctrine of tangible look, as follows:
In the current case, the unique courtroom denied quick reduction on the understanding that the surgical process would have been requested exterior the community acknowledged by UNIMED Recife, whereas the plaintiff, now the appellant, would have been a beneficiary of the UNIMED João Pessoa community.
I maintain that the impugned resolution deserves to be reversed. I clarify.
The well being scheme contracted by the appellant covers the whole nationwide territory.
One of the premises of the UniMed Health Plan is to provide its members a service community for all signed contracts, which brings a bonus generally known as the UniMed System Contract, which might be: “A gaggle of all UniMeds, cooperative organizations of medical work, for the availability of companies to related customers. sure to one another or by contract”. (Source: User Guide).
If UniMed takes benefit of this massive unified framework to seize prospects and such a definition is contained within the contract itself, it can not, whereas offering service or answering for breach of contract, declare that it feels that it doesn’t have a unit. , and so should reply to the arrogance it has woke up and instilled within the buyer within the sense that he might be equally served anyplace within the nation.
The UNIMED system, of which each UNIMED Recife and UNIMED João Pessoa are half, is structured in accordance to the phrases of Law nº 5.764/71, so that a number of autonomous items function in a cooperative regime.
This cooperation between completely different nationwide items permits person service all through the nationwide territory, in a type of change between cooperatives. The integration of the system is evidenced by way of the identical title “UNIMED” and a frequent brand, so as to make it tough, within the eyes of the client, to restrict the obligations and scope or scope of labor. Coverage of every unit is calculated in singular.
There is nice potential for shopper confusion when contracting well being plans provided by the cooperatives that make up the UNIMED system.
Thus, though Unimed Recife and Unimed Joao Pessoa are separate authorized entities, it’s affordable for the patron to consider that the 2 kind a single entity. Especially since that is how UniMed presents itself when advertising and marketing its companies.
The shopper could perceive that the contract for the availability of medical and hospital companies was signed with the nationally acknowledged UNIMED system.
Therefore, the items of Unimed do Brasil are members of the settlement and are collectively and severally liable.
Therefore, as a abstract discovering, I observe the achievement of the required necessities for granting non permanent emergency guardianship, for which purpose I grant the request for suspensive impact to decide that the well being plan proceed with the prices of the surgical therapy.
Prescribed by attending doctor for Radical Prostatovesiculectomy + Retroperitoneal Lymphadenectomy + Posterior Urethroplasty, all robotically, at Unimed Recife Hospital, inside 05 (5) days, beneath penalty, $0000 every day high-quality.
Therefore, it’s concluded that, even when they’re corporations with completely different CNPJs, UNIMEDs all through Brazil work collectively, offering well being coverage to the group as a single unit – and that, for that reason, respect and guarantee ought to