Practice areas
Health insurance disputes and medical law
The plan denied a procedure, raised the monthly premium without a clear explanation, or cancelled the contract. These are the three situations the firm hears about most.
Private health plans in Brazil are governed by Law 9,656/1998 and by the rules of the National Supplementary Health Agency (ANS). The Consumer Protection Code also applies, except to self-managed plans, under Precedent (Súmula) 608 of the Superior Court of Justice. Coverage denials, premium increases and terminations can therefore be challenged in court. The firm has worked in this field since before Law 9,656 existed.
What the practice does in this area
- Review of the coverage denial and of the grounds the health plan operator invoked
- Urgent court applications when health is at risk and the procedure cannot wait
- Challenges to annual premium increases and to increases based on age bracket
- Waiting periods, temporary partial coverage and pre-existing conditions
- Unilateral termination and cancellation of group (employer or association) contracts
- Reimbursement of expenses outside the plan network, where the contract or the law provides for it
- Medical malpractice and the civil liability of health professionals and institutions
The denial must be justified in writing
An operator that denies a procedure must tell the beneficiary, in writing and in plain language, the reason for the denial and the contractual or legal provision it relies on. Keeping that written answer is the first practical step, because it frames the whole dispute.
The ANS list is no longer a closed list
Law 14,454/2022 amended Law 9,656/1998 to provide that coverage can extend to treatment not included in the ANS list of procedures, provided the requirements set out in the statute are met, among them proof of efficacy in the light of health sciences and a recommendation from a recognised technical body.
Urgency and emergency have their own rule
Law 9,656/1998 deals specifically with urgent and emergency care, including the waiting period that applies. When the condition is acute, the legal argument is usually about the immediate duty of coverage, not about the contract in the abstract.
Age-bracket increases have limits
A premium increase when the beneficiary moves into a new age bracket is allowed, but it must be provided for in the contract, follow the brackets set by the applicable regulation and not be disproportionate. The Superior Court of Justice (Superior Tribunal de Justiça) has settled the validity requirements for this clause in a binding repetitive appeal ruling.
Frequently asked questions
Can a Brazilian health plan deny a procedure my doctor prescribed?
It can, but it must justify the denial in writing and in plain language, citing the contractual or legal provision it relies on. If the denial conflicts with Law 9,656/1998, the ANS regulations or the Consumer Protection Code, it can be challenged in court. The treating doctor’s prescription is central to that discussion.
What should I do when the plan denies urgent surgery?
Ask for the denial in writing, keep the doctor’s report describing the urgency and seek advice immediately. In these cases lawyers commonly apply for interim relief (tutela de urgência), a provisional decision a judge can grant before the case ends when there is a risk of serious harm to health. Time is the critical factor.
Can treatment outside the ANS list be covered?
Yes, provided the requirements of Law 14,454/2022, which amended Law 9,656/1998, are met. The statute now allows coverage of treatment not on the list when there is proof of efficacy in the light of health sciences, or a recommendation from a recognised health technology assessment body, among the other situations it sets out.
Is it legal to raise my premium because of my age?
An age-bracket increase is allowed, but it must meet three conditions · it must be written into the contract, follow the age brackets of the applicable regulation and not be disproportionate. Increases that concentrate a very steep jump in the last bracket are the most frequent subject of court challenges.
Can the operator cancel my health plan unilaterally?
It depends on the type of contract. In individual and family plans, Law 9,656/1998 strongly restricts termination by the operator. In group plans, the discussion usually turns on the contract terms, the notice given and whether a beneficiary is undergoing treatment. It is an analysis that depends on the specific contract.
Do I need to complain to the ANS before going to court?
No, it is not mandatory, but a complaint to the ANS, the federal regulator of private health plans, is useful · it generates a protocol number and a formal answer from the operator, which document the denial. In urgent situations, however, the administrative route should not delay an application to the courts.
Informational content only, with no offer of services for any specific case, in line with Rule 205/2021 (Provimento 205/2021) of the Brazilian Bar Association (OAB).