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Wednesday, September 28, 2022

Court rules in favor of prepayment due to default in declaring pre-existing diseases

The Supreme Court of Justice of the Nation struck down two decisions that maintained the affiliation of two individuals with a prepaid drug company who failed to record pre-existing diseases in their respective affidavits before the provider.

These are the cases of BRA and HC, for which – in separate files – the Federal Chamber of Mar del Plata recognized the right to retain affiliation, although they omitted the information in the affidavit, but Swiss Medical SA Private Medicine was given the right to renegotiate the monthly fee. ,

In the first case, the BRA filed an emparo action in 2016 for obtaining a hip prosthesis with antibiotics and associated surgical intervention and hospitalization, whereas, in a more recent case, the HC sought rehabilitation treatment due to drug use. Claimed full coverage of Liquor.

In both cases, Swiss Medical protested with the same reasoning: that the relevant affidavits on illnesses, hospitalizations, operations and accidents prior to affiliation, despite knowing their deformities, had no pre-existing conditions or denial of treatment. were completed together.

The company disagreed with the chamber’s decision and took the cases to the country’s highest court, after recalling that it had a right of disassociation, as provided for in the prepaid medical contract.

With these elements, the Court unanimously agreed with the previous opinion of the financial prosecutor, Viktor Abramovich, who held that the prepaid pharmaceutical company has the right to terminate the contract, in the event that the income affidavit made by the affiliate is falsified. , under the terms of Article 9 of the Act 26,682 (Regulatory framework for such medical benefits).

“The legislator could, in Article 9, reiterate the criteria chosen for the user’s entry with pre-existing conditions and, therefore, prohibit his exclusion and impose a reinforcing fee; but, nevertheless, he did not. Instead, they decided to attribute a specific outcome to deceptive conduct,” Abramovich said.

The Court annulled the sentences with the signatures of its president Horacio Rosatti and ministers Carlos Rosencrantz, Juan Carlos Maqueda and Ricardo Lorenzetti, and ordered that the files be returned to the original court “in order to issue a new proclamation of this decision.” according.”

World Nation News Desk
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