Agreements
All health insurance companies are legally obliged to cover hospital procedures in the specialty of Oral and Maxillofacial Surgery and Traumatology. Patients with health insurance are entitled to the following items:
✔︎ Hospitalization;
✔︎ Medicines;
✔︎ Orthotics and Prosthetics;
✔︎ Complementary Exams.
Maxila Center®, in an attempt to strengthen relations with health insurance companies and guarantee total transparency in the indication of surgeries and the request for materials, will provide the following documents:
- Report Justifying the Need for the Procedures;
- Description Required Procedures;
- Materials to be used in the procedures;
- Justification of the Need for the Materials Requested.
After applying to the health insurance company, it has up to 21 days to authorize the surgery. In the event of refusal, the patient should contact the National Supplementary Health Agency (ANS).
NORMATIVE RESOLUTION – RN NO. 465 OF FEBRUARY 24, 2021
Subsection III
The Hospital Plan
Art. 4 For the purposes of this Normative Resolution, the following definitions are established:
VIII – clinical imperative: a situation in which a procedure in the dental or outpatient segment requires hospital support, due to the beneficiary’s clinical need or condition, with a view to reducing any risks arising from the intervention, as declared by the attending doctor or dentist;
Art. 19 – The Hospital Plan includes care provided in all forms of hospitalization and care characterized as urgent and emergency, in accordance with the specific Resolution in force, not including outpatient care for the purposes of diagnosis, therapy or recovery, with the exception of the provisions of item X of this article, and must guarantee cover for:
I – hospitalization, in all its forms, for an unlimited number of days;
VII – expenses, including food and accommodation, relating to the accompanying person, unless the attending doctor or dental surgeon justifies against it, in the following cases:
a) children and adolescents under the age of 18;
b) senior citizens aged 60 and over; and
c) people with disabilities;
VIII – oral and maxillofacial surgical procedures listed in the Annexes to this Normative Resolution, for the hospital segmentation, as provided for in art. 6, including the request for complementary tests and the supply of medicines, anesthetics, medical gases, transfusions, nursing care, food, orthoses, prostheses and other materials related to the surgical act used during the period of hospitalization;
IX – the hospital structure necessary to carry out dental procedures that can be performed on an outpatient basis, but which, due to clinical imperatives, require hospitalization, with the health team necessary for the complexity of the case, including complementary tests and the supply of medicines, anesthetics, medical gases, transfusions, nursing care and food used during the period of hospitalization; and
X – outpatient procedures, provided for in this Normative Resolution and its annexes, whose need is related to the continuity of care provided during hospitalization:
§Paragraph 1 For the purposes of item IX, the clinical imperative must comply with the following rules:
I – in the case of dental care, the attending dental surgeon and/or the attending physician will assess and justify the need for hospital support to carry out the dental procedure, with the aim of ensuring greater patient safety, ensuring the appropriate conditions for carrying out the procedures, assuming the technical and legal responsibilities for the acts carried out; and
II – dental surgeon’s fees and dental materials used to carry out outpatient dental procedures which, in situations of clinical imperative, need to be carried out in a hospital environment, are not included in the coverage of the hospital segmentation and referral plan.
Common Negatives for Covenants
NEGATIVE ON THE ALLEGATION OF AESTHETIC NATURE
Oral and maxillofacial surgery can be functionally restorative or merely aesthetic. It is functional when it aims to correct deficiencies that affect breathing, speech or chewing, or when it aims to eliminate pain (including headaches). In these cases, therefore, the surgery is not cosmetic in nature. When it is not merely cosmetic, oral and maxillofacial surgery is covered.
For the Judiciary, the surgeon’s report describing the deficiencies to be repaired (breathing, speech or chewing) or reporting pain is enough to rule out the claim of an aesthetic nature and, therefore, to impose coverage of the procedure.
NEGATIVE FOR THE SURGEON NOT BEING PART OF THE HEALTH PLAN’S ACCREDITED NETWORK
Even when the surgeon is not part of the network accredited by the health plan operator, he can still carry out the procedure, as long as his fees are paid by the patient. In this regard, it is worth mentioning ANS Precedent 11 of August 20, 2007, in point 2:11.
The request for hospital admissions and laboratory/complementary tests, requested by the dental surgeon, duly registered with the respective professional councils, must be covered by the operators, and it is forbidden to deny authorization to carry out a procedure solely because the requesting professional does not belong to the operator’s own, accredited or referenced network.
NEGATIVE ON THE ALLEGATION OF LACK OF COVERAGE OF THE PROCEDURE
In regulated and adapted contracts, even if there is no clause in the contract providing for the coverage of oral and maxillofacial surgery, or even if there is a clause stating that such a procedure is not covered, the coverage of the procedure is due, since it results from a legal imposition, which cannot be treated differently in the contract.
In the case of unregulated contracts, the courts have come to the view that the procedure must be covered, including prostheses and orthoses, even if the contract stipulates otherwise.
The Ministry of Justice’s Secretariat for Economic Defense, through Ordinance 3/99, directs judges to recognize the nullity of contractual clauses that “impose, in health insurance contracts signed prior to Law 9.656/98, limits or restrictions on medical procedures (consultations, medical examinations, laboratories and hospitalizations, ICU and similar) contrary to medical prescription.”
Thus, even in regulated contracts, considering the importance of the right to health, the obligation to fully cover oral and maxillofacial surgery has been recognized.
NEGATIVE ON THE ALLEGATION OF LACK OF COVER FOR PROSTHESES AND ORTHESESIS
It is very common, especially in non-regulated plans, for there to be a clause excluding cover for prostheses and orthoses. However, the obligation to cover oral and maxillofacial surgery extends to covering prostheses and orthoses that are fundamental to the surgical procedure.
In other words, when it is not possible to perform the surgery without the use of prostheses and orthoses, the cost of these materials by the health insurance company is mandatory.
In cases of rehabilitation of atrophic jaws, health insurance companies are not obliged to cover the fixed implant-supported prosthesis(es), so the cost of the prosthesis(es) is borne by the patient.
Options for the Injured Patient
If the operator doesn’t authorize the procedure, the patient has a few alternatives:
Going to the State Public Defender’s Office – this option can only be used if the patient does not have the financial means to hire a lawyer, which is considered for people who have an income of less than two minimum wages.
File a complaint with the ANS – this can be done online at www.ans.gov.br or by calling 0800.7019652. It should be made clear that this option can only generate a fine for the operator and is not a means of obtaining the procedure, unless the operator, after being notified by ANS to provide clarification, decides to release the surgery;
Going to the Special Civil Courts – this option can only be used for cases that do not require expert evidence, since the Courts only judge so-called small claims. It will also be a good option for claims for reimbursement or compensation of up to 40 minimum wages. In cases where the value is less than 20 minimum wages, it is not even necessary to hire a lawyer (although it is the most advisable);
Hire a private lawyer – to file a lawsuit against the operator, to obtain a court order authorizing the surgery, and possible compensation for material and moral damages;
