In Brazil, a significant number of individuals seek health insurance with the anticipation of undergoing plastic surgery. However, navigating through the intricacies of health insurance coverage for such procedures can be daunting. According to the National Health Agency (ANS), health insurance plans are obligated to cover only specific types of plastic surgeries. To demystify this seemingly complex and bureaucratic subject, it is crucial for those considering plastic surgery to comprehend how health insurance works and understand their rights.
Reconstructive vs. Aesthetic Plastic Surgery
The ANS, responsible for regulating health insurance plans in Brazil, maintains a list of procedures that every private health insurance plan must offer. Patients can only undergo surgeries listed by the ANS or those explicitly mentioned in their insurance contracts. The ANS's list primarily includes reconstructive surgeries, aiming to restore parts of the body for medical reasons, such as breast reconstruction after cancer.
However, aesthetic surgeries, performed solely for improving appearance without any functional deficit or deformity (e.g., breast augmentation), are not covered by the ANS. Examples of aesthetic surgeries include rhinoplasty and liposuction.
In addition to the inclusion of the preferred procedure in the ANS list, for the execution of reconstructive surgeries, the chosen health insurance plan must be of the ambulatory hospital type. Even if a surgery is on the ANS list, some may have different techniques not covered by default. In such cases, it is essential to verify whether the specific surgical technique is mentioned in the insurance contract.
Covered Reconstructive Surgeries
1. Breast Reconstruction Surgery
Patients who have undergone surgeries for breast cancer removal, such as mastectomy, are entitled to coverage for breast reconstruction. Additionally, those with traumatic injuries or tumor removal should have reconstructive surgery covered by their health insurance.
2. Breast Reduction Surgery
If there is a medical indication for breast reduction due to functional impairments, such as back pain, the beneficiary has the right to have the surgery covered by health insurance.
3. Excess Skin Removal Surgery
Individuals with excess skin after significant weight loss, whether through clinical treatment or surgical procedures, have the right to plastic surgery coverage. The procedure is mandatory due to the risk of complications associated with excess skin.
4. Eyelid Skin Removal Surgery (Blepharoplasty)
The health plan is obligated to cover this procedure in cases where excess eyelid skin causes functional impairment, such as compromised vision. Medical approval and plan endorsement are necessary for coverage, and in case of disagreement, a third-party medical opinion is sought for a final decision.
5. Corrective Procedures for Scars and Burns
While these procedures may have aesthetic implications, they aim to repair health-related consequences. Patients with scars or burns resulting in complications are entitled to coverage for corrective procedures.
6. Coverage for Prosthetics and Orthotics
Prosthetics and orthotics, external devices that aid body function, are covered by health insurance only when listed in the ANS procedures. Coverage for purely aesthetic prosthetics is not mandatory unless specified in the insurance contract.
Health Insurance Plans and Aesthetic Surgeries
Although health insurance plans are generally not obligated to cover aesthetic surgeries, some plans include coverage for plastic surgery as a distinct feature. Such coverage is explicitly detailed in the insurance contract. It is advisable to thoroughly review the covered procedures before committing to a plan. While plans offering coverage for plastic surgeries may be more expensive, they remain considerably more economical than private procedures. Additionally, most plans require beneficiaries to fulfill a waiting period specified in the contract before utilizing the benefits.
Noteworthy Health Insurance Providers for Reconstructive Surgeries
- Bradesco Saúde
These health insurance providers are commonly utilized for reconstructive surgeries, providing coverage for the specified procedures.
Dealing with Rejection of Reconstructive Plastic Surgery Coverage
When health insurance denies coverage for reconstructive plastic surgery, the patient should resort to legal action to seek coverage. It is essential to have a medical report indicating the necessity of the surgery and the insurance plan's denial. The insurance company must provide a written refusal with justification within 24 hours.
For more information on health insurance coverage for plastic surgery in Brazil, visit or . Stay informed and make informed decisions about your health insurance coverage for plastic surgery.