Background
The beneficiaries sued health insurer Hapvida Assistência Médica S.A. after it refused coverage for a PET-CT/PET-SCAN prescribed as part of cancer treatment. Medical reports showed metastases arising from adenocarcinoma of the sigmoid colon. The beneficiaries paid R$3,700 for the examination and sought reimbursement and moral damages.
The trial court ordered reimbursement of R$3,700 and awarded R$10,000 in moral damages. The São Paulo Court of Justice upheld reimbursement but vacated the moral-damages award, imposed reciprocal costs, and set each side’s attorney fees at 15% of the amount in controversy. Hapvida appealed to the Superior Court of Justice, arguing principally that the examination did not satisfy the National Supplementary Health Agency’s coverage guidelines.
The Court’s Holding
The Fourth Panel unanimously considered only part of Hapvida’s special appeal and denied relief. It held that health plans must cover medically prescribed examinations necessary for cancer treatment, including PET-CT or PET-SCAN. A refusal based solely on the examination’s asserted failure to meet the agency’s utilization guidelines is abusive, and the dispute over whether the agency’s benefits list is exhaustive or illustrative does not eliminate coverage for a necessary oncology examination.
The court also found that the state appellate judgment adequately addressed the essential issues. It declined to consider Hapvida’s arguments concerning binding precedent, objective good faith, and the proper basis for calculating attorney fees because those issues had not been addressed below and were not properly preserved for review. The court increased the appellate attorney-fee award against Hapvida by 10% of the percentage previously set, subject to statutory limits and any applicable legal-aid protection.
Key Takeaways
- Brazilian health plans must cover medically indicated PET-CT or PET-SCAN examinations shown to be necessary for cancer treatment.
- An insurer cannot justify denial solely by asserting that an oncology examination falls outside the ANS utilization guidelines.
- Federal statutory arguments generally must be addressed by the lower court and properly preserved before the STJ will consider them on special appeal.
Why It Matters
The decision reinforces the STJ’s established protection for access to medically necessary cancer diagnostics. For insurers and beneficiaries, the key inquiry is the examination’s demonstrated connection to prescribed oncology care, rather than the abstract classification of the ANS benefits list.
The ruling also underscores the procedural importance of preserving each federal issue in the lower court. Even potentially significant arguments about precedent, contractual good faith, or attorney fees may remain unreviewed if they were not properly raised and decided below.