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The 2nd Civil Division of the Court of Justice of the Federal District and Territories (TJDFT) ruled that a health plan user was entitled to compensatory moral damages after being denied hospital admission on the grounds that they failed to comply with the waiting period stipulated in the contract. In this case, the issue is whether the refusal to cover hospital admissions in an emergency situation based on the waiting period stipulated in the contract gives rise to compensation for moral damages.
According to the TJDFT's understanding, health plan providers cannot refrain from covering a medical procedure needed by a beneficiary when the situation is urgent or emergency and the individual's health is critical.
According to the ruling, the argument that the beneficiary failed to comply with the waiting period stipulated in the contract is not supported by the legislation governing health plans and insurance. It further states that Law No. 9,656/1998, in its Article 35-c, items I and II (*), provides for mandatory coverage of care in emergency and urgent cases. The waiting period to be considered when urgency or emergency care is determined, as is the case in this case, is a maximum of twenty-four (24) hours from the effective date of the contract, pursuant to Article 12, item V, paragraph c, of Law No. 9,656/1998.
Concluding that the denial of coverage by the health plan provider was illegal and abusive, the panel ordered the company to pay compensation to the consumer for the damages suffered, in the amount of R$5,000.00, given that the management of health plans is directly linked to the fundamental rights to health, life, and human dignity, protected by Articles 1, item III, and 5, caput, of the Federal Constitution. For more information, see case number 0701610-16.2025.8.07.0001.
Source: TJDFT News.
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