Abusividade nas anuidades de panos privados de saúde para beneficiários incluídos na faixa etária de 59 anos ou mais

Abstract

The present study aimed to demonstrate the presence of abusiveness in the collection of monthly health plans in relation to insured persons who reach the last existing age group, currently, namely: 59 years or more, in the case of individual plans contracted from January 2004. For that, initially, the history of health in the country was brought, firstly approaching the emergence of the SUS. Afterwards, the appearance of supplementary health, object of study of this monograph. Thus, the concept of Abusiveness was observed versus the values of the monthly fees of the health plans in relation to the beneficiaries whose age group is 59 years or older. This is because there are several lawsuits that request revisions in the monthly fees of the insured who go from the age of the 9th age group (54 to 58 years old) to the 10th age group (59 years old or more), in view of a high increase in monthly fees, when there is this change of range. Thus, with the possibility of abuse, the beneficiaries seek justice to plead the correction of any illegality. This time, we sought, through actuarial analyses (actuarial expertise), to calculate the legal amounts to be charged in the 03 lawsuits studied. At the end of these calculations, added to the analyzes of the current legislation, it was concluded that, in the cases studied here, the supplementary health insurance companies actually charged abusive amounts, being condemned to return, in double, the amounts received in the past, as well as as corrected, in addition to readjusting charges to legal levels. Therefore, through the study in question, it is possible to glimpse how the correct pricing of monthly fees should be, observing, for that, the norms of ANS, CDC, CF and other legal diplomas, avoiding judicializations and, thus, financial losses for the insurance company of health.