Abstract
To analyze publications regarding judicial demands related to the violation of the rights of the client who uses private health insurance in Brazil. Integrative review, from September to October 2017, of national character, with complete texts online, in Portuguese and English, published between 2012 and 2017 in the Virtual Health Library portal, excluding studies that were duplicated or with indiscriminate methodology. The judicial demands were for: medication (32%); ward hospitalization (11%); surgical procedures (9%); orthosis, prothesis and special materials (9%); others (9%); and diagnostic procedures, outpatient service, hospitalization in Intensive Care Units, food formulas and disposable diapers (30%). The prevalence of legal disputes arising from the failure in providing health service by private health insurances was observed, which makes it easier for the administrators to identify the sought health products and services in order to reorganize the administrative sphere and provide quality care.
Highlights
Within health law, the obligation of the State is to ensure full, universal and free access to health services, as described by the basic premises of the Brazilian Unified Health System (SUS)(1)
The creation of the SUS, through the Federal Constitution of 1988(3), and its regulation by the Organic Health Law aimed at the reorganization of the health system in order to ensure the access to the right to health, seeking to modify the situation of inequality in health care through the mandatory public service to any individual, prohibiting the collection of any amount for the service provided(1,4)
When checking the judicial demands resulting from health insurance plans, health products and services are mentioned in the scientific productions(12,14-18,21-26), as well as the demands within the administrative sphere in relation to resource allocation and the function of interconnection between the three branches of the Government(19-20)
Summary
The obligation of the State is to ensure full, universal and free access to health services, as described by the basic premises of the Brazilian Unified Health System (SUS)(1). The creation of the SUS, through the Federal Constitution of 1988(3), and its regulation by the Organic Health Law aimed at the reorganization of the health system in order to ensure the access to the right to health, seeking to modify the situation of inequality in health care through the mandatory public service to any individual, prohibiting the collection of any amount for the service provided(1,4). The ANS should regulate the relationship between users and providers of health services, aiming, among other things, at minimizing consumer law violations, since health insurance plans can deny providing services(8) In these circumstances, since it is impossible to solve the conflict at the administrative level, those interested have to seek the judicial sector to obtain the medicine or treatment denied by the health system, a theme named “judicialization of health”(9). It is worth highlighting the limitation of the study, which includes several formats of scientific production in the sphere of research elements for publication and, among other aspects, it is seen that not all journals request the same data: data collection, analysis and results are impaired, which hinders the correlation of the research data for the perfect result in reaching the most comprehensive picture
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