Health plans rise 80% for children

Health plans for autistic children are up to 80% more expensive because of the annual readjustment. O UOL spoke with three mothers who claim that the health plan of Unimed (National Confederation of Medical Cooperatives) had 79%, going from R$ 385.67 to R$ 689.65 for their children, aged between five and seven years.

The company says the increase is in line with the contract. Families are filing lawsuits to review the readjustment or are bearing the costs to ensure that treatments are maintained.

Shopkeeper Camila Paradella, 38, from São Paulo, is the mother of Raul, 5, a child on the autistic spectrum. In April, she received a statement that the health plan would be 80% more expensive.

Due to the volume of therapies that Raul has to do every week, Camila stopped working to dedicate herself to her son’s treatments.

She received proposals from other brokers to change her health plan, but preferred to seek justice, since the clinic where her son is treated today only accepts her current plan, from Unimed. Camila got an injunction that suspended the 80% increase.

In the decision, the Court authorized the maximum adjustment applied to individual plans, which is 15.5% this year. For now, Camila awaits the collection of the plan next month to see how much the new value will be, after the injunction.

Camila, alongside Raul, Tiago (Raul’s father) and Valentina (sister)

Image: Personal collection

“I paid the highest amount in May and June for a basic plan, with infirmary. It is a very limited plan and I had never had such a high readjustment. Last year it was 7.51%”, says Camila.

Camila says that she and her husband, Tiago Morales, 36, were going to hire a health plan for their eldest daughter, Valentina, 8, but they gave up, as Raul’s increase in the plan left the financial situation even tighter.

By email, Qualicorp, the company that manages Raul’s plan, says it tried to negotiate the lowest possible readjustment value.

“This year, despite all the efforts of its benefits administrator, in an attempt to negotiate the lowest possible rate, its operator defined the percentage of 80%”, says Qualicorp in an email sent to Camila.

The app driver Elisia Rafaela, 30, also suffered an 80% readjustment in the plan of her son Pietro, 7. Elisia filed a lawsuit to review the costs, which were too high for her pocket, but unlike Camila, she is still waiting the decision of the Court.

Elisia and Pietro;  health plan readjustment - Personal collection - Personal collection

Elisia, Pietro’s mother, filed a lawsuit to review the readjustment

Image: Personal collection

“Either I pay the lawyer or pay the plan. I needed to have made the payment on June 20, but I’ll only get it at the end of the month. It’s impossible to pay both with the 80% increase”, says Elisia.

She says she looked for another health plan, but couldn’t get the change, saying that her son is an autistic child.

“I tried to migrate to another operator and they said that there was not much to do. They said that it was not feasible to make the switch, especially when I said that my son has autism”, says Elisia.

Health plans talk about the increases

Sought by the report, Qualicorp says that the adjustment was punctual and represents about 0.5% of all the company’s customers and that the contract is no longer commercialized.

“Qualicorp currently has the largest product offering platform in the country, with 108 operators and more than 700 health plans. To date, more than half of its customers have already chosen to migrate to new plans with similar or even lower prices, including of the operator itself. This offer, which remains active, should further expand the adhesion”, says the company in a note.

In a note, Unimed says that it does not establish contracts directly with the beneficiaries, because it works exclusively with corporate contracts.

“However, note that the adjustment applied is in accordance with the rule provided for in the contract with the administrator”, says Unimed in a note.

Can the plan charge more for a person with a disability?

Rafael Robba, a lawyer at Vilhena Silva, says that, in theory, health plans cannot apply a different adjustment for people with disabilities.

When the plan is individual, the adjustment is limited by the ANS (National Supplementary Health Agency). In the case of collectives, the operators define the readjustment percentage.

As the operators calculate the adjustment according to the use of the plan by the beneficiaries, Robba says that, if one of them is an autistic child, for example, who undergoes a series of treatments, this use can cause the operator to apply higher adjustments. .

“If a company that has 60 lives registered in the plan, and among them one is a child with the autistic spectrum, this cost is divided into the company’s plan. Another situation that can usually generate a differentiation for the beneficiary’s cost is when the plan has co-participation. The fee paid when using the plan, if he uses a lot, it will have a higher cost”, says Robba.

However, Robba says that increases such as 80% are not usually well-founded, and operators cannot prove in court the need for such a strong increase.

Operators cannot refuse people because they are undergoing treatment, as long as they meet the prerequisites determined by the ANS for portability, such as having an active contract with an operator, being up to date with the monthly payments and having fulfilled the minimum period of permanence in the plan.

“As autism treatment is expensive and can reach more than R$ 50 thousand per month, some plans use the strategy of abusive increases to expel the consumer from their beneficiary base”, says Tatiana Viola de Queiroz, a lawyer specializing in health and consumer law.

The decision of the STJ (Superior Court of Justice) that obliges the plans to attend only what is in a predefined list, should not provoke changes in the policy of readjustments of the operators.

Bonding is part of the treatment

“An autistic child who depends on therapies and has a bond with professionals cannot simply change the plan. The bond is part of the treatment. In these cases, it is worth fighting in court, even if the process takes time to complete”, he says. viola.

This was one of the reasons that made Camila seek justice and not try to change Rau’s plan.

“If I change plans, I have to get the plan to release the therapies and go through a process of adapting it to the clinic”, says Camila.

Mother bears readjustment for fear of missing treatments

Danielle and Isadora;  health plan readjustment - Personal collection - Personal collection

Danielle with her daughter, Isadora, 5 years old

Image: Personal collection

Physiotherapist Danielle Fidélis, 37, is the mother of Isadora, 5. Today, she has an injunction in court that authorizes her daughter’s treatments in a specialized clinic and, therefore, she was afraid to appeal against the 80% increase she also suffered. in the health plan.

As the process regarding therapies has not yet been finalized, Danielle said she was afraid to contest the adjustment.

“It was out of fear, because the process has not yet been finalized. We still have the injunction, and the plan cornered us. They said to look for another plan if we are not satisfied”, says Danielle.

Alternatives to consumers who have more expensive health plans are to try to negotiate with the operator, seek another plan for portability or file a lawsuit in court to review the adjustment.