O autismo e a judicialização da saúde suplementar: coberturas negadas, desafios legais e decisões do TJ-PB no ano de 2024.

Abstract

This study aims to analyze whether the refusal of health insurance providers to cover certain therapies for individuals with Autism Spectrum Disorder (ASD) has legal support, considering Brazilian legislation and the case law of the Court of Justice of Paraíba (TJPB). The methodology employed involved both qualitative and quantitative approaches, through the legislative and jurisprudential analysis of 28 civil appeals involving health insurance companies and ASD beneficiaries. The research revealed that, despite the normative progress in ensuring rights for people with autism, there are still barriers that hinder the effective realization of these rights, particularly in the healthcare field, leading to a high rate of judicialization. The analysis of TJPB decisions demonstrated a favorable pattern toward beneficiaries, ordering the coverage of therapies prescribed by physicians, even when such therapies were not included in the list of procedures provided by the National Supplementary Health Agency (ANS). Additionally, the study identified recurring generic arguments from insurers, suggesting a potentially delaying nature in their refusals. Thus, this study contributes to the discussion on the need for regulatory and oversight improvements in the supplementary health sector and highlights the crucial role of the Judiciary in safeguarding the rights of individuals with ASD.