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Health Plan must bear emergency medical expenses regardless of shortage


The judge of the 4th Civil Court of Brasília granted the anticipation of protection pleaded by the plaintiff and determined that the company Amil Assistência Médica Internacional LTDA should provide instruments for and pay for the hospitalization and medical treatment of the applicant, performing urgent cesarean surgery, regardless of the scope of the grace period provided for in the contract.


The plaintiff, holder of the health plan linked to Amil Assistência Médica Internacional LTDA, alleged a 38-week pregnancy, presenting fetal macomonic bradycardia and polyhydramnios, with high maternal and fetal risk, making it extremely urgent to perform a cesarean surgery, clinical condition confirmed in a medical report that stated that the author needed to be hospitalized due to the condition presented, requesting an urgent cesarean. However, despite the seriousness of the case shown in the medical report, the defendant refused to cover hospital expenses, on the grounds of non-compliance with the contractually established grace period.


According to the magistrate, the action deals with a demand that seeks to safeguard the fundamental rights to life and health of the plaintiff, and is also a case of extreme urgency, in view of the serious condition in which the patient was. Thus, the judge ordered Amil to pay for the immediate hospitalization and medical treatment of the applicant, regardless of the scope of the grace period provided for in the contract signed between the parties, in accordance with the provisions of art. 35-C of Law 9,656/98, with the wording given by Law 11,935/2009, which provides: "The coverage of care is mandatory in cases: I - emergency, defined as those involving immediate risk of life or injury irreparable for the patient, characterized in a statement by the attending physician; II - of urgency, understood as those resulting from personal accidents or complications in the gestational process".


In this way, the magistrate granted the effects of the interlocutory relief to determine that Amil authorize the defraying of all expenses arising from the applicant's hospitalization, as well as the defrayal of all necessary examinations, materials and procedures of the beneficiary, under the terms of the medical indication presented, under penalty of daily fine, in addition to possible appropriate criminal liability.


The sentence was published in the DJ-e on 7/29/2015. It is appealable.


Process: 2015.01.1.070532-3




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