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Court Confirms That Health Plans Must Reimburse Expenses In Emergencies Outside The Credited Network. Decisions Ensure Full Refund And Protect Patients.
Thousands of Brazilians purchase health plans believing they have a guarantee of quick and efficient care. But in practice, it is not uncommon for patients to face denials when seeking care at hospitals or clinics outside the credited network in emergency situations. The good news is that courts across the country have reiterated that, in cases of urgency and emergency, operators are obliged to fully reimburse medical expenses. This measure is based on the supplementary health legislation and the regulations of the National Agency for Supplementary Health (ANS), which govern the sector.
What The Law And ANS Say About Reimbursement In Emergencies
Law No. 9,656/1998, which regulates health plans in Brazil, is clear:
- In cases of urgency and emergency, if there is no possibility of immediate care from the credited network, the plan must fully reimburse the patient’s costs.
- ANS emphasizes that urgency includes situations that risk life, such as severe accidents, heart attacks, strokes, emergency childbirth, and complications from chronic diseases.
In other words, it is not up to the health plan to choose where the patient should be treated when there is a risk of death. The priority is to save lives.
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When Reimbursement Is Guaranteed
According to decisions already confirmed in higher courts, the patient can demand full reimbursement in three main situations:
- Absence of a hospital or specialist available in the credited network.
- Unjustified denial by the plan to authorize the procedure.
- Life-threatening risk requiring immediate care, with no time to travel to a credited hospital.
Real example: A patient in São Paulo had a heart attack and needed care at a private hospital outside the network. The plan denied reimbursement, but the court ordered full restitution of R$ 68 thousand in medical expenses, in addition to compensation for moral damages.
Emblematic Cases Judged By The Court
- The STJ (Superior Court of Justice) has already ruled that health plans cannot impose barriers in medical emergencies, determining full reimbursement for hospitalizations in private hospitals when there was no time for travel.
- In 2024, the TJ-SP condemned an operator to reimburse R$ 32 thousand to a patient with a neurological crisis who needed urgent surgery outside the network.
- In Rio Grande do Sul, a family managed to obtain reimbursement of R$ 45 thousand after paying for an emergency childbirth at a non-credited clinic, as the hospital indicated by the plan had no available spots.
These precedents show that courts have reinforced consumer protection and punished operators that refuse to comply with the law.
How Consumers Should Act In Case Of Denial
Patients facing reimbursement denials should follow some fundamental steps:
- Keep all payment receipts, invoices, and medical reports.
- Formally request reimbursement from the plan, with a service protocol.
- If there is a denial, file a complaint with ANS through the website or by calling 0800 701 9656.
- If there is still no solution, resort to the courts, which have been ruling in favor of plaintiffs in most cases.
In many cases, in addition to reimbursement, the Judiciary orders payment of compensation for moral damages, ranging from R$ 5 thousand to R$ 20 thousand, depending on the severity of the case.
The Financial Impact Of The Decisions
The obligation for full reimbursement in emergencies represents a relief for consumers, but also raises concerns among operators, who claim rising costs in the supplementary health sector.
According to ANS, in 2023 alone, more than 120 thousand complaints were registered against health plans, with a significant portion related to coverage denials in emergencies.
Experts argue that operators need to expand credited networks and improve bed regulation, instead of shifting risks onto patients.
Consumer Rights And Health As A Priority
The understanding among courts reinforces a fundamental principle: in life-threatening situations, the right to health must prevail over any contract or restrictive clause.
The logic is simple: no one chooses where they will have a heart attack, a car accident, or a serious complication. Therefore, courts have been ensuring that patients are fully reimbursed, without financial loss.
Court Reinforces: In Emergencies, Health Plans Must Pay
The jurisprudence is already consolidated: health plans cannot deny reimbursement in emergencies. This rule applies throughout Brazil and is supported by both law and ANS regulations.
In practice, this means that thousands of consumers are entitled to significant amounts back whenever they had to pay out of pocket for emergency care outside the credited network.
For many, it is not just about getting the money back, but ensuring that life and health are prioritized over any contract. And this is a victory for consumers that can save not only finances but also lives.
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