As of March 19, 2014, the Brazilian National Supplementary Agency (Agência Nacional de Saúde Suplementar – ANS) has officially started to mediate conflicts unrelated to assistance matters arising out of contracts between consumers and healthcare carriers.
Such mediation role is not entirely new to ANS; the agency has been mediating conflicts since 2010, but up until last March 19 it dealt only with assistance-related disputes.
What disputes ANS deems to be assistance and non-assistance in nature? The distinction is not always obvious and there is no clear-cut line between both categories. Typically, assistance-related matters include complaints concerning coverage offering and medical care, such as failure by carriers to schedule appointments and medical proceedings within the minimum established time frames, denial of coverage of medical proceedings, denials and delays by carriers to reimburse insureds, etc.
ANS claims a success rate of 85.5% in 2013 in resolving conflicts which were assistance in nature. Such high rate of positive results encouraged the agency to broaden the scope of its mediation activities towards non-assistance disputes too. Examples of non-assistance issues that might give rise to complaints before ANS include excessive price adjustments dictated by carriers, unilateral termination of contracts, etc., which have more to do with legal or technical matters than medical care itself.
The mediation proceeding for both assistance and non-assistance matters is regulated in detail in Normative Resolution No. 343, enacted by ANS in December 2013. The proceeding has been named NIP, which is the acronym of Preliminary Intermediation Notification (Notificação de Intermediação Preliminar).
In a nutshell, in assistance-related NIPs, healthcare carriers will be given a five (5) (business) day-notice to take the necessary measures to resolve the complaint with the consumer. Such term will be ten (10) business days in NIPs that are non-assistance in nature. In either case, the healthcare carrier must upload its answer, along with supporting documentation, on ANS' website showing whether the complaint has been resolved or why it understands the consumer's contentions to be groundless. Failure to provide a timely answer will subject the carrier to a separate sanctioning procedure.
Whether the mediation of non-assistance matter will prove successful is yet to be seen. Hopefully in the long run such initiative of ANS will help increase the quality of services delivered by carriers and reduce the ridiculous amount of healthcare litigation flooding the courtrooms in Brazil.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
