The news “Perfect storm in health insurance where reimbursement has become a risk” published this week in the newspaper O Globo refers to a specific situation related to health insurance.
The expression “perfect storm” indicates that several unfavorable factors are combining, which results in a problematic situation for insurers and policyholders.
In the context of health insurance, reimbursement is an essential part of the service, because it guarantees that policyholders can be reimbursed for medical expenses covered by the contract.
According to the news, some of the reasons for this perfect storm in health insurance are: rising healthcare costs, growing demand for medical services, an aging population and the emergence of new technologies and more expensive treatments.
These factors are putting pressure on insurers to make a greater number of reimbursements, at the same time that they need to balance their finances and cover expenses.
As a result, some insurers are experiencing difficulties in honoring all reimbursements satisfactorily, which ends up generating dissatisfaction among policyholders.
Supplementary Health has negative results in the first half of the year
The sector closed the first half of this year with a negative operating result of R$ 4.3 billion. This accounts for earnings from monthly fees and the costs of user health care, administration and brokerage.
Insurance companies — which account for 13.3% of the 50.7 million supplementary health users — are going through a particularly difficult time. While health plan service is restricted to the accredited or own network, health insurance offers the free choice of doctors and laboratories by the consumer for reimbursement as a differentiator. But this reimbursement became the target of fraud, causing enormous damage to the sector.
FenaSaúde, the federation that represents insurance companies in the sector, has already filed three criminal reports with the São Paulo Public Ministry asking for the investigation of evidence of fraud totaling R$ 51 million against nine operators.
— The reimbursement culture has become a mechanism of fraud and abuse. We have been working with a focus on the consumer so that they can be our ally, paying attention to situations in which they are used as an instrument to carry out fraud that weighs heavily on the cost. In the end, it is paid for by all users — says Vera Valente, executive director of FenaSaúde.
Denied refund increases consumer complaints
In the opinion of Ana Carolina Navarrete, coordinator of the health program at the Brazilian Institute for Consumer Protection (Idec), under the pretext of combating fraud, insurance companies have been denying due reimbursements and delaying reimbursement deadlines, which has resulted in an increase in complaints of the consumer.
— There are cases of undue denials, reimbursements in wrong amounts and delays. All of this can compromise consumers with a limited budget, especially in cases of continuous treatments. Fighting fraud is important, but it cannot be a justification for denying coverage or poor service provision — highlights Ana Carolina.
In Vera's assessment, the sector is experiencing a “perfect storm” and, to recover sustainability, it will be necessary to re-discuss expectations regarding health plans with society. She highlights that 40% of health plan users are with operators that are in the red:
— The number of young people between 20 and 29 fell by 7.6%, from 2013 to 2023, according to data from the National Supplementary Health Agency. In the same period, that of people over 60 years old rose more than 30%. With the aging of the population, the generational pact, in which younger people pay more to finance older people, is at risk. This adds to the speed at which new technologies are incorporated, with costs that can be millions of dollars. All of this makes actuarial calculations in the sector challenging.
