Unimed must compensate the patient for refusal of coverage in home care

The Third Civil Chamber of the Court of Justice of Paraíba (TJPB) upheld the 11th Civil Court of the Metropolitan District, which upheld the claims for material and moral compensation against Unimed João Pessoa – Cooperativa de Trabalho Médico, as a result of the refusal to cover the service called Home Care.

According to the Appeals Records (0867835-62.2018.8.15.2001), the patient requires home care service, as he is affected by amyotrophic lateral sclerosis (ALS). However, the service was denied on the grounds that there was no contractual coverage.

“In the case of these records, the medical report is clear regarding the need for home care of the appellant, detailing the reasons for the prescription,” the reporter said, adding that in such cases, the Supreme Court’s understanding is fair that the service called “home care” is an extension For services provided in the hospital, and the health plan operator cannot refuse the patient, if recommended by doctors.

With regard to moral damage, the reporter noted that “the unjustified refusal by the health fund operator to allow the coverage of home care duly provided for the treatment of illness covered by the plan constitutes irreparable moral damage, as it has exacerbated the psychological distress and pain in the The soul of the patient, because when he refused the necessary treatment, which is necessary to improve him, he was already in a state of pain, shock, and poor health.”

Thus, Unimed’s conviction was maintained by paying R$5,000 as moral compensation. The reporter pointed out that “the value set by the court that issued the judgment serves punitive and compensatory purposes.”

With information from the Court of Justice of Paraíba.

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