Health Insurance Must Cover Post-Bariatric Procedures

Court ruled in favor of the patient The issue of contractual coverage by health insurance plans is back in the spotlight due to repeated attempts by operators to evade their obligations. In a recent case, a certain health insurance beneficiary had her request for coverage of a reconstructive surgery denied administratively — a procedure prescribed by a licensed professional and which, according to judicial understanding, should be included in the contractual coverage. According to lawyer Pedro Nunes - responsible for the action - this is a situation that unequivocally characterizes a consumer relationship, and therefore, the provisions of the Consumer Protection Code are applicable. "The denial by the plan is abusive, especially because the procedure in question did not have an aesthetic purpose, but rather a reparative character, essential for the physical and emotional recovery of the patient after bariatric surgery previously authorized by the operator itself," he says. It cannot be admitted, from a contractual and legal perspective, that medical assistance is limited to the coverage of bariatric surgery — considered a treatment for morbid obesity — without encompassing its natural and expected developments, such as reconstructive surgery. The contractual object of health assistance is based on ensuring the appropriate technical means for the restoration of the patient's health, and must keep pace with the evolution of treatments recognized by the medical community. According to Nunes, when joining a health plan, the consumer trusts that the procedures indicated by licensed doctors and compatible with the contractual coverage will be made available to them in a timely manner. "This is, therefore, a legal and contractual obligation of the health operator, which cannot be relativized by unilateral administrative decisions or by restrictive interpretations of coverage," he emphasizes. In the present action, the Nunes Santos Advocacia firm obtained a favorable ruling, condemning the health plan to perform the reconstructive surgery and also to compensate for moral damages, due to the undue refusal of treatment and the suffering experienced by the patient. The decision represents an important precedent for the protection of consumer rights, especially regarding essential services such as health. In addition to rectifying an individual injustice, the ruling reaffirms the social function of the contract and the duty of good faith of the operators.