The denial must be in writing, and that changes everything
The first practical step is not legal, it is documentary. An operator that denies a procedure has a duty to tell the beneficiary the reason for the refusal, in writing and in plain language, citing the contractual or legal provision it relies on.
That written answer frames everything that follows. Without it, the argument stays in the territory of what was said over the phone. With it, the operator is bound to the grounds it chose, and those grounds are what the dispute is about.
Always ask for the protocol number. If the written answer never comes, a complaint to the National Supplementary Health Agency (Agência Nacional de Saúde Suplementar, ANS), the federal regulator of private health plans, usually produces it, because the complaint opens a procedure with a response deadline.
Which law applies to your plan
Health plans taken out from 1999 onwards are governed by Law 9,656/1998 and by ANS regulations. Older contracts, known as "old plans", follow their own regime unless they were formally adapted.
In addition, the Superior Court of Justice (Superior Tribunal de Justiça) settled in Precedent (Súmula) 608 that the Consumer Protection Code applies to health plan contracts, except those run by self-managed entities. In practice, that means ambiguous clauses are read in the beneficiary’s favour and abusive terms can be struck down.
The ANS list is no longer a closed list
For years, the dispute was whether an operator could deny anything that did not appear on the ANS list of covered procedures. Law 14,454/2022 amended Law 9,656/1998 and settled the question at the level of statute.
The list became a baseline reference, and coverage can extend to unlisted treatment when the requirements set out in the statute itself are present.
- Proof of the treatment’s efficacy in the light of health sciences
- Or a recommendation from the National Commission for the Incorporation of Technologies into the Unified Health System (Comissão Nacional de Incorporação de Tecnologias no Sistema Único de Saúde)
- Or a recommendation from at least one internationally renowned health technology assessment body, provided the treatment is also approved for that body’s own nationals
- A prescription from the treating physician or dentist
Urgency and emergency follow a different logic
When the condition is acute, the dispute cannot wait the ordinary length of a lawsuit. Law 9,656/1998 deals specifically with urgent and emergency care, including the waiting period that applies.
In these cases, lawyers commonly apply for interim relief (tutela de urgência), a provisional decision a judge can grant before final judgment when the evidence shows a probable right and a risk of serious harm. The treating doctor’s report, describing the urgency and the reason for the prescription, is the central document.
What to gather before seeking advice
A consultation is far more productive when these documents are already at hand.
- The written denial and its protocol number
- The plan contract and the beneficiary handbook, if there is one
- The treating doctor’s report and prescription, with the clinical justification
- Test results and medical reports supporting the prescription
- Proof that the monthly payments are up to date
- The history of contacts with the operator, with dates and protocol numbers
Frequently asked questions
How long does the operator have to answer a request for a procedure?
The ANS sets maximum service deadlines by type of procedure, counted from the beneficiary’s request, and they vary with the nature of the service, from a basic appointment to elective hospital admission. Missing the deadline is, by itself, grounds for an administrative complaint and can support a court application.
Can the operator deny coverage over a pre-existing condition?
It can apply temporary partial coverage to high-complexity procedures, high-technology beds and surgery linked to the declared condition, for the maximum period the regulation allows. Once that period ends, the restriction ceases. Denying coverage on the ground of an undeclared pre-existing condition requires the operator to prove the omission, and merely asserting it is not enough.
Should I complain to the ANS before going to court?
In non-urgent situations, yes · the complaint generates a protocol, forces a formal answer and frequently resolves the matter. In urgent situations, the administrative route should not delay a court application, because administrative deadlines do not keep pace with the seriousness of the condition.
Can I pay for the procedure and claim reimbursement later?
Reimbursement can be argued when payment was made in the face of a wrongful denial and there was urgency. But that route adds a burden · besides showing the denial was wrongful, you must prove the outlay and its necessity. When there is time, obtaining a court decision before paying is usually the safer position.
The plan cancelled my contract during treatment. Is that allowed?
It depends on the type of plan. In individual and family plans, Law 9,656/1998 strongly restricts termination by the operator. In group plans, the discussion involves the contract terms, the notice given and, significantly, whether a beneficiary is in ongoing treatment, a situation Brazilian courts examine with particular attention.
Informational content only, with no offer of services for any specific case, in line with Rule 205/2021 (Provimento 205/2021) of the Brazilian Bar Association (OAB).