Health Law: health plans, treatments and patients' rights in Brazil

Relationships with health plans in Brazil are regulated by Law No. 9,656/1998 (in Portuguese), by the rules of the National Supplementary Health Agency (ANS) and, as a rule, by the Consumer Protection Code. A coverage denial usually has reasons such as:

• a procedure considered outside the contracted coverage;
• a waiting period;
• lack of prior authorization or of an indication considered sufficient;
• a gap between what the doctor prescribed and what the operator authorizes.

Not every denial is improper, and not every denial is legitimate. The analysis checks the type and date of the contract, the coverage, what the law and ANS rules establish for that procedure, the justification given in writing, the attending physician's indication and the urgency of the case. Depending on the situation, it is possible to challenge the denial with the operator itself, file a complaint with the ANS or assess a court measure.

Ongoing therapies, such as those prescribed to people with autism spectrum disorder (for example, ABA therapy), raise frequent questions. The ANS has rules on coverage of therapies for pervasive developmental disorders, and the attending physician's indication weighs in the analysis, but coverage is not automatic in every case.

The following are usually relevant:

• the report of the professional who prescribed the therapy, with frequency and duration;
• what the contract and the regulation provide for that type of care;
• the accredited network and the possibility of adequate care;
• the denial or limitation issued by the operator, in writing.

Home care is health care provided at home. Whether a health plan covers it depends on the contract, ANS rules and the patient's condition. The analysis usually considers:

• the medical indication for home care and the need for continuous care;
• the contract clauses on hospitalization and care at home;
• the comparison with hospital admission and the alternatives offered;
• the documents that prove the clinical situation.

Each case is assessed with its own documents, and no result is guaranteed.

The supply of high-cost medication may involve the health plan or the public authorities (the public health system, SUS), depending on the case. Courts usually examine the proven need for the medication, the existence of alternatives and registration with the National Health Surveillance Agency (Anvisa).

• Health plan: contract, coverage and ANS rules;
• SUS: official lists, protocols and criteria set by case law for medication outside them;
• the medical report and tests that support the request;
• urgency and deadlines.

We do not claim that every denial is unlawful: the conclusion depends on each situation.

Patients have the right to information about the diagnosis, the risks and the treatment alternatives, and may accept or refuse interventions, as a rule, after free and informed consent. They also have the right to privacy: under Brazil's General Data Protection Law (LGPD), health data is treated as sensitive data.

• access to the medical record and to information about the care received;
• consent to treatments and research;
• decisions about one's own treatment, including advance directives;
• confidentiality and proper use of health data.

Health professionals, clinics and institutions have their own legal needs:

• service agreements and contracts with health plan operators;
• professional liability and the duty to inform the patient;
• confidentiality and protection of health data;
• partnerships between professionals and organization of the practice;
• defense in complaints and lawsuits.

Bioethics and Biolaw deal with the ethical and legal limits of health decisions: patient autonomy, informed consent, end-of-life decisions, research with human beings and the use of new technologies. The education in Law, Biology and Bioethics of part of the team allows the legal aspect to be examined in dialogue with the clinical and ethical ones.