Planos de saúde e medicamentos de alto custo: entre o direito à saúde e os limites contratuais

Abstract

This study addresses the right to health within the private sphere, focusing on the obligations of health insurance providers to cover procedures and treatments arising from the contractual relationship established with their users. More specifically, it analyzes access to high-cost medications from the perspective of consumer relations. The theme emerges in the context of increasing judicialization of health care due to the frequent denial of coverage by private health plans, as well as ongoing discussions about the legal and regulatory limitations on access to treatments within these contractual frameworks. Furthermore, the relevance of the topic is reinforced by the fundamental and social nature of the right to health, and the need to reconcile this status with its application in private legal relationships. Among the objectives of the study, particular emphasis is placed on assessing the legal feasibility of requiring coverage for exceptional medications by health insurance providers. As for methodology, this is an applied research study, with an inductive and quali-quantitative approach, and a descriptive objective, developed through bibliographic research and case law analysis. It is concluded that, according to the Superior Court of Justice, private health insurance coverage for high-cost medications intended for home use is not mandatory, subject to certain exceptions—such as medications used in cancer treatment or injectable drugs that require administration by a healthcare professional.