What are the most prominent features of the project?
These are the main changes proposed by the bill, according to Sandro Raimondo, lawyer member of the Special Committee on Insurance and Reinsurance Law at OAB-SP:
Unilateral suspension or termination of group plans is prohibited: The bill expands the prohibition on unilateral suspension or termination of health plan contracts by operators/insurers to include group plans. Under current law, this prohibition applies only to individual contracting plans.
Operators will be asked to justify the refusal of the procedure or service: If authorization to perform the procedure or service requested by the insured’s physician is denied, the operator must communicate in detail, through a written document, in clear and appropriate language, the reason for denying authorization for the procedure or service, indicating the contractual or legal condition that justifies it.
Greater transparency in licensing application procedures: Authorization application processes to perform procedures or tests must be transparent, allowing the user to monitor progress and reasons for potential delays or denials of coverage, including digitally.
Establish rules and limits for joint participation: The project specifies that joint participation should be limited to 30% of the value of health procedures or events, while also respecting the plan value ceiling. It also stipulates that in the case of treatment in psychiatric hospitals, there can be no participation; It does not prevent joint participation in relation to hospitalization in general, or for other medical specialties.
