Plano deve custear tratamento de criança com síndrome de Asperger – Jornal Pequeno – MARANHÃO Hoje- Notícias, Esportes, Jogos ao vivo e mais

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Decisão unânime da 2ª Câmara Cível do Tribunal de Justiça do Maranhão manteve sentença da 9ª Vara Cível de São Luís, para determinar que a Geap Autogestão em Saúde autorize e custeie integralmente o tratamento de criança, representada no processo por seu pai e sua mãe, em procedimento terapêutico com equipe multidisciplinar, com profissionais especialistas no tratamento de criança diagnosticada com transtorno do espectro autista, conforme relatórios médicos, de forma ininterrupta e contínua em sua rede credenciada. O plano de saúde também foi condenado a pagar R$ 10 mil, em indenização por danos morais. Ainda cabe recurso da decisão.

De acordo com o entendimento da sentença de 1º grau e da decisão do órgão do Tribunal, na hipótese de não haver profissionais habilitados, o plano deve efetuar o ressarcimento integral, no prazo de 30 dias, dos valores pagos de procedimentos que o plano não autorizar ou não possuir credenciados.

O plano de saúde alegou não obrigatoriedade de custeio de tratamento pelo método ABA, que considera altamente dispendioso, não coberto pelo plano de saúde e sem previsão no rol da ANS.

Também afirmou que a parte autora da ação na Justiça de 1º grau não contratou a extensão de qualquer tratamento e que, embora garanta a assistência de terapeuta ocupacional e fonoaudiólogo, não está obrigado a fornecer quaisquer outras subespecialidades elencadas para tratamento de autismo, baseado nos métodos ABA, Teacch, Prompt, Denver, integração sensorial e demais terapias, conforme rol de cobertura obrigatória da ANS.

VOTO

O relator das apelações do plano e de representantes da criança, desembargador Guerreiro Júnior, fundamentou seu voto com base em recente resolução normativa, a RN nº 539/2022, em que a Diretoria Colegiada da Agência Nacional de Saúde Suplementar (ANS) ampliou as regras de cobertura assistencial para usuários de planos de saúde com transtornos globais do desenvolvimento, entre os quais está incluída a síndrome de Asperger, um estado do espectro autista.

O desembargador também citou entendimentos do Superior Tribunal de Justiça. Segundo Guerreiro Júnior, o STJ considera abusiva a cláusula contratual que exclui tratamento prescrito para garantir a saúde ou a vida do beneficiário, uma vez que a operadora de plano de saúde pode estabelecer as doenças que terão cobertura, mas não o tipo de terapêutica indicada por profissional habilitado na busca da cura.

Na sequência, disse que o STJ tem reconhecido a impossibilidade de limitação das quantidades de sessões de terapia destinada ao tratamento de portadores do espectro autista e, em decisão recente, assegurou o tratamento baseado no método ABA para criança ou adolescente com menos de 18 anos portador de transtorno do espectro autista.

Também baseado em precedentes do STJ, acrescentou que a recusa indevida ou injustificada pela operadora em autorizar a cobertura financeira de tratamento ou exame médico a que esteja legal ou contratualmente obrigada, gera direito de reparação a título de dano moral, em razão de a medida agravar a situação física e psicológica do beneficiário.

Entendeu que o valor de R$ 10 mil atende aos parâmetros de razoabilidade e proporcionalidade, considerando sua dupla função – compensatória e pedagógica –, o porte econômico e conduta da empresa.

A desembargadora Nelma Sarney e o desembargador Jamil Gedeon, convocado para compor quórum, também negaram provimento ao apelo da operadora de saúde e deram provimento ao apelo da mãe e do pai da criança, de acordo com o parecer do Ministério Público do Estado.

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