As these unlawful activities proliferate, the health and pockets of millions of Brazilians are seriously threatened
Health insurance plays a pivotal role in medical, hospital and dental care for millions of Brazilians. However, in recent years, there has been a growing problem in the industry: fraud relating to the refund of medical expenses.
Official data reveals that, in Brazil, more than 50.5 million citizens depend on assistance enabled by health insurance, with another 30.9 million receiving dental care under these contracts. The legal regulation of these services is provided for under Law 9656/98, which ensures the right of beneficiaries to refund of medical and hospital expenses when they use services outside the accredited network.
The refund, as determined by law, is calculated based on the amount paid by the health insurance operator to accredited professionals in its network, as well as considering contract limitations, when it is a free choice, wherein the user chooses the providers that will serve them, such as physicians, clinics, and laboratories. This is where fraud gains ground.
According to the National Supplementary Health Federation (FenaSaúde), in 2019, refunds for medical expenses summed up to about BRL 6 bn. In 2022, this amount increased significantly, reaching almost BRL 11 bn. The figures prompt questions about the legitimacy and transparency of these refunds.
Insured persons themselves can be victims of fraud and have their personal data misused. A characteristic example is that of cosmetic and weight loss clinics that promise supposedly free treatments, entirely covered by health insurance, but request the beneficiary’s login and password to defraud the class of services provided and make refund requests on behalf of the beneficiary. Often there are inflated costs and procedures that have not been performed or, in even worse cases, the beneficiary’s current account is changed to divert the amounts refunded.
It is worth questioning the reason why non-accredited physicians, clinics, and laboratories show interest in providing care to a patient, bear the costs involved, and run the risk of default. The answer lies in the increased amounts of medical services that these non-accredited providers can charge, as well as the ability to divert patients from the referenced network.
The Superior Court of Justice (STJ) has expressed concern about these practices. In November 2022, the Justices rendered that “The right to refund depends, by logical assumption, that the beneficiary of the health insurance has actually previously disbursed the amounts with health care, and it is also essential to comply with the other legal requirements provided for in the Health Insurance Act. Only then will the insured acquire the right to refund of the medical expenses incurred. Before that, there will be a mere expectation of right ” (Special Appeal (REsp.) No. 1.959.929/SP).
As fraud in health insurance looms large, transparency and protection of beneficiaries become urgent issues, impacting not only operators, but also the pockets of beneficiaries.
Available at: https://www.jota.info/opiniao-e-analise/artigos/reembolso-sem-desembolso-fraudes-colocam-planos-de-saude-e-beneficiarios-em-risco-31102023
Autor: Gaya Lehn Schneider Paulino • email: gaya@ernestoborges.com.br • Tel.: +55 67 3389 0123
