Access to health goods and services in health plans through the judicialization: a study of the State of São Paulo

• Autor(a) principal: Freitas, Beatriz Cristina
• Data de Publicação: 2022
• Outros Autores: Queluz, Dagmar de Paula
• Tipo de documento: Artigo
• Idioma: por
• Título da fonte: Cadernos Ibero-Americanos de Direito Sanitário (Online)
• Texto Completo: https://www.cadernos.prodisa.fiocruz.br/index.php/cadernos/article/view/859
• topic: Judicialização da saúde; Saúde suplementar; Direito à saúde; Políticas de saúde; Planos de pré-pagamento em saúde; Judicialización de la salud; Salud complementaria; Derecho a la salud; Judicialización de la salud. Federalismo Políticas de salud pública. Financiación de la asistencia sanitaria. Poder Judicial.; Planes de prepago de salud; Judicialization of health; Supplementary health; Right to health; Health policies; Health prepayment plans

Objective: to analyze access to health goods and services of health plans through judicialization, describing the profile of actions, implications of the right to health and health management. Methods: exploratory, descriptive research, in which 513 judgments of the São Paulo Court of Justice were analyzed, from 2007 to 2017. Results: the results indicate negative coverage (42.45%), and problems related to contracts (26.20 %), readjustments (16.50%), accredited network (7.20%), retired and dismissed workers (7.00%) and moral damages (0.65%). Among the exclusions from coverage, 46% of health plan users sought access to coverage for the treatment of diseases or health-related events: medications (28.7%), exams (18.5%), orthoses and prostheses (12.5%) and hospitalization (12.00%). In 82% of the judgments, the court decisions were favorable to the users. Conclusion: judicialization for access to health goods and services from health plans mainly involves denials of coverage (exclusions and limitations of coverage) and contractual conflicts (mainly old contracts). Within the limits of this research, it can also be concluded that there are indications that health supplement managers need to think about redirecting some of their behaviors, verify faults and dysfunctions, and observe possible gaps in rules or laws for the regulation of consumption in the supplementary health care system, seeking as well to minimize judicialization and achieve more comprehensive health care practices in this segment.