Health plan denied treatment · SPD Advocacia
Did the health plan deny it? Request the surgery or exam with an injunction
Surgeries, tests, hospital stays, prostheses and procedures outside the ANS list. See when a denial is abusive and tell us about your case urgently.
Straight answer
Can a health plan deny a procedure that is not on the ANS list?
Since Law 14,454/2022, the ANS list is the basic reference, but it does not cover everything. Treatments outside the list must be covered when there is proof of effectiveness based on scientific evidence or a recommendation from technical bodies, such as Conitec. In addition, the plan must respect the ANS maximum service deadlines, and denials without written justification can be challenged, including with an injunction.
What the law says
Patient rights
Treatments outside the list can be covered, under the criteria of the law.
The plan must state the reason for the denial in writing, if asked.
There are maximum waiting times for appointments, tests and surgeries.
In urgent and emergency cases, coverage is mandatory 24 hours after the plan is taken out, under the law.
Source: Law 9,656/1998, arts. 10, § 13, 12 and 35-C, with Law 14,454/2022; ANS rules.
What is your case?
Situations the firm handles
Procedure recommended by the doctor
Request for an injunction when there is risk.
Law 9,656/1998High-cost tests
MRI, PET scan and genetic tests, depending on the case.
Law 14,454/2022Materials denied or swapped
The doctor chooses the material, not the health plan.
Case reviewDenial due to waiting period
In urgent and emergency cases, the waiting period is 24 hours.
Law 9,656/1998, art. 12Temporary partial coverage
Limits and exceptions of partial coverage.
Case reviewOut-of-network care
Reimbursement according to the contract and ANS rules.
Case reviewStep by step
How the firm works
- Quick review. We check the medical indication, the denial and the contract or the SUS rule.
- Documents. We guide the medical report and organize the denial, tests and protocol numbers.
- Request. Complaint, notice or lawsuit with a request for an injunction, depending on the urgency.
- Follow-up. Enforcement of the decision, renewal of prescriptions and new denials.
Case review
Let's review your case
Answer the questions, one at a time. At the end you can attach documents, which go straight to a folder in the firm's Drive, and send the summary via WhatsApp. Everything is protected by attorney-client confidentiality.
Common questions
Frequently asked questions
How do I ask for the denial in writing?
Through the plan's customer service. The insurer must state the reason in clear language.
How long does the injunction take?
In urgent cases, the request can be reviewed within a few days or even the same day.
Does filing a complaint with the ANS help?
It helps and may resolve the issue, but does not prevent a lawsuit.
Does a group plan have the same rights?
Minimum coverage is the same. Price adjustments and cancellation follow different rules.
Do you serve clients outside Anápolis?
Yes. Service is provided at the firm's office in Anápolis, or online for all of Goiás and other states.
How much does it cost?
After the analysis, the firm sends a written fee proposal before any engagement.