Did you know that many people struggle to get reimbursement from their health insurance providers?
Whether due to a medical emergency or the need to see an unaccredited specialist, dealing with health insurance reimbursement may seem impossible.
However, knowing your rights and understanding how health plan reimbursement works is critical to ensuring that you don't lose money.
In addition, when it comes to reimbursing professionals not accredited by the operator, many people are unaware of their rights and end up giving up after the first refusal of the request.
That's why we prepared this comprehensive guide to help you navigate the entire refund process, from the necessary documentation to what to do in the event of a denial.
Read this guide and discover how to guarantee your rights and receive your refund.
Understand your rights to a refund
The right to reimbursement of health insurance is guaranteed by Law 9,656/98 and regulated by the National Supplementary Health Agency (ANS) [1]. Therefore, it is essential that you know the situations in which you may require this right.
Is every healthcare provider required to reimburse?
Not necessarily. To understand if you are entitled to reimbursement for services performed outside the accredited network, we first recommend that you read the contract with your health insurance provider.
Check the specific clauses that detail the conditions under which refunds are granted for exams, appointments, and other procedures.
However, there are specific situations where reimbursement is guaranteed by law.
Situations where reimbursement is guaranteed by law
Your health plan is thanks to make the refund in the following situations:
- Urgent or emergency cases when it is not possible to use the accredited network
- Absence of accredited professionals or establishments in your municipality
- When the referenced network refuses or is unable to provide the service [2]
That is, when any of the situations described above occur and you need to pay for a private health service, you are entitled to reimbursement for that cost.
However, it is important to note that this obligation does not apply to elective procedures, that is, those that are not classified as urgencies or emergencies.
In addition, it is crucial to be aware that your health plan may have its own rules for situations that are not covered by this requirement.
Some operators, for example, offer reimbursement when the patient opts for an unaccredited professional. Thus, thoroughly verifying the clauses of your contract is essential.
Legal deadlines for request and payment
After submitting the complete documentation, the operator has 30 days to make the refund, counting from the date of request. [1].
It is worth noting that in the case of compensation for damages caused by non-compliance with an obligation under a health insurance contract, you have up to 10 years to request reimbursement of medical and hospital expenses [3].
Reimbursement limits and amounts
In cases of urgency or emergency without the possibility of using the accredited network, you have the right to full reimbursement, including travel expenses [1].
In addition, when there is no provider in the municipality, the operator must guarantee service by an unaccredited provider with full reimbursement [4].
It is worth remembering that in plans without the free choice modality, the reimbursement limits may vary as stipulated in the contract, and may not always fully cover the amount paid for the service. However, the reimbursement amounts cannot be lower than those charged in the accredited network [1].
It is important to note that clauses that limit reimbursement in an abusive way can be challenged in court [5]. Therefore, pay attention to the amounts offered by the operator.
Step by step to request a refund
To ensure the success of your health plan reimbursement claim, it's critical to follow an organized process. Initially, we will cover each step necessary for you to receive your refund without setbacks.
Documentation required for the order
To request a refund, you will need to gather the following documents:
- Invoice or original receipt for the service provided, containing:
- Patient's full name
- Detailed description of the procedure
- Date of service
- Amount paid
- Professional identification
- Medical report (in cases of urgency/emergency)
- Proof of bank payment [6]
Caution: some documents are NOT required!
Each operator has their own rules regarding reimbursement. However, the National Supplementary Health Agency (ANS) — the regulatory body of health operators — determines guidelines common to all plans.
For example, as described in ANS Refund Booklet, health operators cannot require documents without justification, such as the registration with the CNES of health providers and professionals, under penalty of regulatory violation.
If your operator requires this document at the time of the request, we recommend that you contact the operator. If the situation is not resolved, we suggest filing a complaint with the ANS.
Where to find the correct form from your operator?
Each healthcare provider has their own documentary requirements. Here are links with detailed guidelines from the main operators:
- Unimed - Refund FAQ
- Bradesco Saúde - Documentation
- Amil One - Refund Request
- Hapvida - Refund Procedure
- Porto Seguro - Refund Request
- South America - Ways to Request a Refund
What to do in case of refusal?
Did you receive a denial of your refund request? Understand the most common reasons and learn exactly how to proceed to guarantee your rights.
Main reasons for refusing
According to official data, operators often deny refunds for the following reasons:
- Absence of contractual coverage for the procedure
- Unfulfilled grace period
- Lack of full documentation
- Procedure not previously authorized
- Exclusion of coverage in the contracted plan [9]
How to contest a refusal
When receiving a denial, follow these fundamental steps:
- Request a written refusal from the operator
- Gather all supporting documentation
- Contact the plan's ombudsman
- Document all resolution attempts
- Keep copies of all protocols [9]
Important: The operator has 30 days to review and pay the refund after the delivery of the complete documentation [1].
Complaint channels at ANS
If the operator maintains the negative, you can file your complaint with the ANS through ANS official website.
When you file your complaint with the ANS, your operator will have between 5 and 10 business days to respond, depending on the nature of the problem [10]. Consequently, if there is no resolution, the ANS may open an administrative procedure that may result in a fine for the operator.
Attention: In cases of persistent denials, you have up to 10 years to file a lawsuit [11]. Furthermore, when the refusal is considered unjustified, the operator may be fined by the ANS in accordance with article 91 of RN 489/22 [10].
Conclusion
Requesting reimbursement from the health plan doesn't have to be a complicated task when you know your rights and follow the correct procedures.
The law guarantees your right to reimbursement in specific situations, especially during emergencies or when the accredited network is not available.
Remember that complete and organized documentation represents your greatest ally in this process. Keep all receipts, fill out forms carefully, and keep records of all communications with your carrier.
If you face a refusal, don't give up. You have several options available, from the operator's ombudsman to the official ANS channels. Be sure to seek what is yours by right.
The success of your claim for a refund depends primarily on your preparation and knowledge. The more you understand about the process, the better your chances of getting your money back hassle-free.
FAQs
1. In what situations am I entitled to reimbursement from the health plan?
You have the right to reimbursement in cases of urgency or emergency when it is not possible to use the accredited network, when there are no accredited professionals or establishments in your municipality, or when the referenced network refuses or is unable to provide assistance.
In addition, depending on the type of contract you have with the operator (such as plans with free choice), you may be entitled to reimbursement even in non-emergency situations.
2. What is the deadline for receiving reimbursement from the health plan?
After submitting the complete documentation, the operator has 30 days to make the payment of the refund.
3. What documents are needed to request a refund?
To request reimbursement, you must present the original invoice or receipt for the service provided (containing the patient's name, description of the procedure, date, amount, and professional identification), medical report in cases of urgency/emergency, and proof of bank payment. Attention: professional registration with the CNES is not mandatory. Learn more at ANS Refund Booklet.
4. What should I do if my refund request is denied?
If your request is denied, request the denial in writing, gather all supporting documentation, contact the plan's ombudsman and, if necessary, file a complaint with the ANS through Official site.
5. Is there a limit to the amount of the refund?
In cases of urgency or emergency without the possibility of using the accredited network, you are entitled to full reimbursement, including travel expenses. For contracts with free choice of providers, the reimbursement amounts cannot be lower than those charged in the accredited network.
It is worth remembering that in plans without the free choice modality, the reimbursement limits may vary as stipulated in the contract, and may not always fully cover the amount paid for the service
References
[1] - https://www.gov.br/ans/pt-br/assuntos/consumidor/o-que-o-seu-plano-de-saude-deve-cobrir-1/reembolso
[6] - https://www2.geap.com.br/REEMBOLSO/documentacao-necessaria.asp
[7] - https://www.costabrasilsaude.com.br/dicas-para-agilizar-o-reembolso-do-seu-plano/
[11] - https://www.doutoresprotect.com.br/blog/reembolso-no-plano-de-saude/
