Você possui plano de saúde e, ao realizar uma solicitação, ela foi negada? Independente de qual for o pedido, pode existir uma maneira de recorrer a esta decisão! Entenda nesta postagem tudo sobre o assunto:
- Negativa de atendimento e internação com urgência:
Com frequência os planos negas aos clientes a autorização de atendimento ou internação com urgência. Porém, independente da motivação, o atendimento de urgência não pode ser negado. O prazo de carência para casos neste sentido são, por lei, de somente 24 horas. Logo, se ocorrer do plano manter o posicionamento de negativação poderá ser considerado como omissão de socorro, configurando crime.
- Negativa de cirurgias e exames:
Em mesmo sentido, é comum o questionamento a respeito de negativa pelo plano de saúde na realização de cirurgias ou exames necessários já indicados por um profissional da saúde. Os exames considerados mais complexos e alguns tipos de cirurgias podem ser negados, contudo, é direito do paciente compreender a justificativa dada pelo plano de saúde e analisar se será válida. Em determinados casos, a negativa poderá ser considerada abusiva e indevida.
- Negativa de medicamentos:
Muitos pacientes buscam auxílio jurídico ao se deparar com negativa de medicamentos não apenas realizado pelo plano de saúde, mas também pelo SUS. Principalmente em casos do doenças mais gravosas é necessário a recomendação médica de tratamentos utilizando medicamentos de alto custo. E, ao ser negado o acesso e cobertura dos medicamentos, os pacientes se encontram em situação de ausência de condições para obtenção de medicação.
Nesta situação, o paciente pode buscar afastar a negativa entrando com um processo judicial em busca de assegurar o tratamento devido.
- Negativa de tratamento
Ao ser surpreendido com uma negativa de tratamento ao solicitar a autorização ao plano de saúde o paciente se vê abandonado pelo seu convênio. Todavia, é importante esclarecer que o plano de saúde não pode negar um tratamento prescrito pelo médico. A Lei prevê a cobertura de tratamentos de todas as doenças listadas na CID-10, sendo abusiva toda e qualquer cláusula contratual que exclua a cobertura pelo plano de um tratamento de doença já previsto.
O que fazer ao receber uma negativa do plano de saúde?
Se você recebeu uma negativa do plano de saúde, é preciso entrar em contato com o plano para pedir a revisão, caso o plano não mude sua posição pode ser aberta uma reclamação na agência nacional de saúde, além do Procon. Em caso de ausência de resolução, busque apoio de um advogado especialista na área para ajuizar uma ação.
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