Pre-existing disease: can not the health plan accept me?

Pre-existing disease: can not accept the health plan I?

When hiring a health plan, the more information the better. But to get this information, you may run into complicated contracts and full details. One of the concepts that can confuse you, for example, is the pre-existing disease – topic that usually generates a lot of controversy, both in the medical field as the legal.

The health plan can not be denied treatment if you have any illness prior to purchase health insurance. But may charge additional fees, as you will see below.

Today, almost 36 million Brazilians are affiliated with health insurance providers, insurers since self-management institutions and managed care providers. This important segment of the population must have their rights guaranteed, their demands met and their health conditions improved.

We gathered in the following topics, all you need to know about pre-existing disease. Follow:

What is pre-existing disease?

All health insurance contracts provide that the contractor fill out a form to report if they have any disease already diagnosed (eg cancer, myopia, diabetes, etc.).

According to information from the National Health Agency (ANS), are diseases and preexisting lesions (DLP) those that the contractor know you have and need to be informed in the health declaration form to hire the health plan.

The operators of health plans may give temporary partial coverage for up to 24 months for these diseases from the plan of the hiring date.

What is temporary partial coverage?

It is the suspension:

  • Coverage of complex procedures and hospitalization in

    • high-tech beds;
    • Intensive Care Centers (CTI);
    • Intensive Care Units (ICU);
  • Surgeries resulting from preexisting conditions, for a specified period.

In general, this period is 24 months and is determined in the contract. After this period, the covering is now complete for all medical procedures that are necessary.

As an alternative to this restriction, the health plan provider may offer the grievance.

What is wrong?

Grievance is when the consumer pays an additional amount in the monthly fee to have access to coverage that could be suspended for up to 24 months, such as those mentioned before.

If the operator does not give regular coverage for illnesses and preexisting injuries, ANS requires it to offer temporary partial coverage – but it need not necessarily work with the grievance.

It is important to emphasize that health providers are required by law to protect the information provided in health statements. They are sensitive information, and the operator may not disclose or provide such information to third parties.

If there is a breach of any contractual provision or legislation, the NSA should be communicated. The agency acts in a community basis, ie, regulates and supervises all health insurance companies and penalizes be breaking the law.

Why should I inform you that have pre-existing disease?

It is important to inform the health plan contract form if you know of any disease that has already been diagnosed as cancer or diabetes. Otherwise, the absence of such information may be considered fraud and may void the validity of the contract with the operator of the health plan.

But if there is a discrepancy regarding the termination or suspension of the contract, it will open an administrative proceeding at the Ministry of Health to trial. Until the final decision, it is not allowed to contract suspension.

Watch! When the patient is already on treatment of their pre-existing disease, health operator continues with the treatment – however, the costs can be charged to the patient.

What are the types of coverage available?

There are 3 types of health insurance:

individual contracts or family

Signed between the beneficiary and the operator, with healthcare coverage and rules for monthly adjustments for cost variation and aged variation.

business collective agreements

Signed between the contractor, the union or association and health provider with healthcare coverage and rule for monthly adjustment for age variation.

In these contracts, adjustments for cost variation are decided between the parties, with no maximum rate to be applied.

It can also be in this type of contract, the adjustment by accident, ie an adjustment based on the plan of using indexes.

collective contracts by adhesion

In this type of contract, affiliated to the legal entity (company, union or association) choose whether or not to participate in the plan. The difference is that the business group plans, all persons related to the company are automatically included in the plan.

Onset of the disease is the same as the early symptoms?

No. The onset of symptoms is independent and is different from disease onset. Are two situations that are not equivalent and do not have the same meaning.

In some cases, this determination can be accurate, as the pain that the patient feels to have a heart attack. In this situation, you can set up in minutes even when the pain began. Also when it comes to a cerebral hemorrhage, the onset of symptoms can be indicated with accuracy of minutes or hours.

But in many other situations, it is difficult and even impossible to define the onset of symptoms. There are cases where the development of the disease is slow and silent. Thus, the determination of its beginning is inaccurate.

Certain anemias, for example, have very subtle early symptoms, which can remain unnoticed for several months or years.

In addition to the anemia, cerebral aneurysms (protrusion cerebral arteries due to the weakening of its wall) are also not discovered by chance in the course of investigation of brain images.

Such aneurysms only symptoms when break – which may never happen. It can not determine when they started the pathological processes that culminated in the dilation and rupture of a possible aneurysm.

From a legal point of view, the onset of symptoms can be determined only in some circumstances. So it can not be considered by the law as a universal and absolute possibility.

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