Brazilian judicial rulings on health insurance

Brazilian courts have issued several rulings aimed at protecting consumer rights against health insurance providers. In São Paulo, the Court of Justice (TJ-SP) addressed the issue of “false collective” plans, where corporate contracts involve very few members, such as a single family. The court ruled that these small groups lack the scale to dilute risks, meaning they should be treated as individual or family plans subject to National Health Agency (ANS) price caps rather than corporate adjustment indices.

Additionally, the TJ-SP ruled that providers cannot refuse coverage based on pre-existing conditions under the guise of “commercial disinterest,” which the court identified as a form of risk selection.

Expanding on these protections, the Superior Tribunal de Justiça (STJ) ruled that providers are prohibited from abruptly terminating coverage for multidisciplinary treatments for beneficiaries with ADHD (TDAH), even during the unilateral rescission of a collective contract. Coverage must be maintained until the patient reaches medical discharge, clinical stabilization, or successfully transitions to a new plan.