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Coverage Denials in Health Plans Are Rapidly Increasing, But Consumers Can Turn to ANS, Lawyers, and Justice to Ensure Essential Treatment
The scene repeats itself in hospitals and clinics: a requested exam, a scheduled surgery, or an essential treatment. However, when the patient seeks coverage from the health plan, they receive the response they don’t want to hear: denial. This increasingly frequent problem generates insecurity, frustration, and often a direct risk to life.
According to data from the National Supplementary Health Agency (ANS), complaints about coverage denials increased by 374% in the last decade.
In 2014, there were 61,500 complaints, a number that jumped to 292,000 in 2023. In just the first four months of 2024, the reports reached 104,000, a 35% increase compared to the same period the previous year.
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This growth reveals not only the dissatisfaction of users but also the need for greater clarity regarding their rights against the operators.
Health Plan: Most Common Reasons for Denying Coverage
Accounts from consumers follow patterns. Many procedures are denied on the grounds of being outside the ANS’s list. Others involve the justification that the treatment is not covered by the plan.
Frequent cases also include the so-called “off-label” use, when the medication is prescribed for a purpose different from that indicated in the technical sheet, or the claim that the treatment is experimental.
There are also denials based on contractual waiting periods, surgeries classified as non-urgent, and refusal to provide high-cost medications or home care.
Despite the arguments, a significant portion of denials is overturned when analyzed in court or confronted with opinions from ANS itself.
What to Do When Faced with a Denial
The first step is to request the denial in writing. The formalization, made on paper or electronically, is essential as proof in any potential disputes.
Next, the patient can file a complaint directly with ANS. The agency offers assistance via telephone at 0800 701 9656 and also on its online platform. In many cases, just this notification prompts the plan to reverse its decision.
When the situation involves urgency, such as surgeries or high-risk therapies, the recommendation is to seek a lawyer or the Public Defender’s Office.
In these circumstances, it is common for the courts to grant injunctions requiring immediate coverage, under penalty of fines and sanctions against the operator.
The Impact of the New Legislation
The topic has gained new contours with the enactment of Law No. 14,454/2022. The rule amended the Health Plans Law (Law No. 9,656/1998) and changed how the ANS’s list is interpreted.
Before the change, the understanding was that the list was exhaustive. In other words, only the procedures expressly listed were subject to mandatory coverage.
This view restricted access to innovative therapies, especially for rare diseases.
With the new law, the list became illustrative. That is, the list serves as a minimum reference but does not prevent coverage of treatments outside of it, as long as they meet established criteria.
Which Criteria Define Mandatory Coverage
According to the law, plans are required to cover procedures not listed when one of the following requirements is met:
- The treatment shows efficacy supported by scientific evidence;
- There is a recommendation from the National Commission for Incorporation of Technologies in SUS (Conitec);
- There is a recommendation from an internationally recognized health technology assessment body, provided it is also approved in Brazil.
According to lawyer Marcel Sanches, a specialist in private law and health, the law has brought more security to patients.
He highlights that “in practice, it is rare for high-cost medications not to be mandatorily covered, as doctors seldom prescribe experimental substances or those without scientific support.”
Rapidly Growing Litigation
Despite the legal advancement, conflicts continue. In 2024, Brazil recorded about 300,000 new lawsuits against health plans, according to a survey by the São Paulo Medical Association based on data from the São Paulo Court of Justice and national projections.
The number more than doubled in just three years and is already the highest since the National Justice Council began monitoring in 2020.
This shows that, even with current legislation, operators continue to resist covering certain treatments.
How the Courts Have Decided
The courts have adopted a firm stance against abusive denials. For example, the Fourth Panel of the Superior Court of Justice ruled that a health plan should cover treatment using the medication Rituximab, even when indicated off-label, as long as the medication was registered with Anvisa.
The decision reinforces the application of Law No. 14,454/2022 and makes it clear that refusal is considered abusive when there is medical and scientific backing.
This understanding has been consolidating and strengthens the position of patients seeking to secure their right to treatment.
Studies also show a high success rate in these actions. Research published by Scimago Institutions Rankings revealed that in cases such as providing medications, consumers win 89% of the time.
A Right That Needs to Be Defended
Denying care has become a common practice for many operators, but the law guarantees defense mechanisms. It is up to the patient not to accept the denial as a final response.
Seeking the denial in writing, contacting ANS, and turning to the courts when necessary are paths that have proven effective.
The increase in complaints and lawsuits proves that consumers are increasingly willing to fight for their rights.
More than numbers, these cases reveal stories of lives that depend on access to an exam, medication, or surgery.
And they clearly show that denying coverage is more than just a contractual issue: it is a struggle for health preservation and, often, for life itself.
With information from Terra.
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