A group health plan by membership (plano de saúde coletivo por adesão) is a type in which the beneficiary may file an action against the unilateral termination of the contract.
The STJ analyzed an appeal against the decision of the Court of Justice of São Paulo (TJSP). The latter had found that the beneficiary was not a legitimate party to file the action.
The group health contract was entered into by Fecomércio (the sponsor) with Golden Cross. The service provider terminated the contract unilaterally. In the appeal to the STJ, the plan beneficiary asserted his active standing to file the action challenging the termination of the contract.
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The reporting justice of the appeal, Justice Nancy Andrighi, explained that group health plans naturally operate in favor of the final beneficiaries of the healthcare service. A reasoning that “authorizes the user of a group health plan to individually file an action against the operator to challenge abusive provisions of the contract, regardless of whether the contracting was intermediated by the legal entity to which he is linked.”
Group health plan
The justice recalled that the challenged act – the unilateral termination – indistinctly and necessarily affects all beneficiaries. For Nancy, the possibility that the unilateral termination may be “abusively carried out by the operator” is a factor capable of justifying that the beneficiary file an action challenging the act deemed unlawful.
“The fact that the contract is collective does not prevent the beneficiary from individually seeking the judicial relief that is favorable to him. That is, the restoration of his contractual bond with the operator. Something that, in theory, was unlawfully severed,” she states.
Nancy emphasizes that other beneficiaries may likewise exercise the right of action to challenge the termination, or wait for the legal entity (the sponsor) to seek the solution in favor of the collectivity of beneficiaries.
Active standing, according to Nancy, is restricted to the purely abstract examination of the ownership of the interests involved in the dispute. And over the course of the proceeding, the merits of the claim must be determined as well-founded or not. But not the conditions of the action, as the TJSP had understood.
With this understanding, the Third Panel annulled the judgment that had extinguished the proceeding without resolution of the merits and ordered the regular adjudication of Golden Cross’s appeal. The judgment had found the termination of the contract unlawful and ordered the operator to compensate the beneficiary for moral damages.
The information is from the STJ.
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