Litigation of hospital care denied by private health insurance and plans in the state of S?o Paulo

This article revisited the legislation and changes i n the sectorial regulation of healthcare coverage from 1998 to 2020, and analyzed 2,845 decisions issued by the S??o Paulo State Court of Justice in 2018 related to coverage denial against health insurance beneficiaries. Inpatient coverage, among which surgeries and hospitalizations stand out, was the main object of the claims, accounting for 41% of the analyzed decisions. Most of the denied inpatient coverage was not included on the list of health procedures and events of the Brazilian Regulatory Agency for Private Health Insurance and Plans. This agency???s regulation, especially the List of Health Procedures and Events, is related to the exclusion of hospital coverage by private health insurance, and is used as an argument for the legal defense for coverage denial together with contractual provisions. The S??o Paulo State Court of Justice, in most cases (80%), guaranteed the inpatient coverage claims, basing such decisions on the Consumer Protection Code, on Jurisprudence, on the Court???s precedents and on Law no. 9.656/1998 (Health Insurance Law). In conclusion, when upon, the Judiciary tends to recognize the right of consumers to access health care coverage, often in opposition to sectorial regulation by the Brazilian Regulatory Agency for Private Health Insurance and Plans.