After request for hospitalization denied, client asks for compensation of R$ 13 thousand

After a health plan denied a request for a necessary hospitalization due to complications from Covid-19, the client demanded a indemnity of more than BRL 13 thousand. What happened was in the state of São Paulo. The patient had to bear all expenses for the period he had to stay in a hospital in Guarujá, which is part of the accredited network of his plan.

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The fact occurred in July last year, when the client was admitted to the Casa de Saúde hospital in Guarujá. According to the judges, the information present in the patient's care record indicated that the hospitalization would have been carried out by the health insurance. The hospital confirmed this information.

With that, Judge Alexandre das Neves, who is part of the Special Civil Court of Guarujá, informed and dismissed the action. After this decision, the defense lawyer, Geraldo de Souza Sobrinho, appealed against the decision, which was accepted. by the judges of the 5th Civil Panel of Santos of the São Paulo Court of Justice as partially proceeding.

Health plan denied hospitalization

According to other information, the plan would have considered transferring the patient to another hospital, which was also accredited by the agreement, which was in the city of Santos. Place next to Guarujá. The decision was justified by the fact that the costs of the hospital were very high.

One of the clauses informs that the agreement covers general hospital, clinical hospitalizations and surgical hospitalizations in all accredited spaces. With that, the case's rapporteur, Dario Gayoso Junior, informed that the agreement should have borne the costs of hospitalization, as the hospital in Guarujá is accredited to the agreement's network.

The data indicate that the plan did not authorize the hospitalization, which meant that the client had to bear all the costs of the hospital. The rapporteur also claimed that this is not a refund for the proper use of the agreement, but an indemnity where it should be fully refunded the amount disbursed by the customer with correction additions and with interest of 1% per month, counted until the moment of the payment.

The agreement in question is NotreDame Intermédica. They issued a note stating that the client, in need of medical care, went to the Casa de Saúde hospital in Guarujá. All the necessary medical care was provided there with the authorization of the health plan. The company also reported that the care unit was not part of the elective hospitalization network and, therefore, was made available the client's trip to another hospital that had full coverage of hospitalization for his type of health insurance.

According to the group, from the moment the agreement alerts the client and the same happens to not opt ​​for the change, he was deciding on a private hospitalization in the hospital in Guarujá, where he was already.

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