2024-04-07 11:24:00
By Silvia Zarza
Lawyer graduated from UNNE, Director of Zarza & Asociados
Special for El Litoral
In Argentina, good faith in affiliation contracts with prepaid medicine companies is a fundamental principle that regulates the relationships between the parties involved, that is, between the prepaid medicine company and the affiliate. Good faith implies that both parties must act honestly, loyally and transparently at all stages of the contractual relationship.
To this end, it is essential that the following be taken into account when entering into the contract:
Clear and precise information: The prepaid medicine company must provide clear and precise information about the services it offers, as well as the conditions and costs of membership. This includes details about coverage, exclusions, waiting periods, co-payments, among other relevant aspects.
Prohibition of abusive clauses: prepaid medicine companies cannot include abusive or unclear clauses in affiliation contracts. Abusive clauses are those that generate a significant imbalance in the rights and obligations of the parties, to the detriment of the member.
Mutual obligations: Both the prepaid medicine company and the affiliate have mutual obligations that must be fulfilled in good faith. For example, the company must guarantee the provision of medical services as stipulated in the contract, while the member must pay the corresponding fees in a timely manner.
Transparency in changes: If the prepaid medicine company decides to make changes to the conditions of the contract (for example, changes in coverage or costs), it must inform members in a clear and timely manner. Good faith implies that these changes cannot be arbitrary or unjustified, and that they must respect the rights of the members and above all when it comes to increases in benefits, they must maintain the parameters of reasonableness so that the hiring of This service, which is essential because it is health, does not leave the person without coverage at a time of greatest vulnerability.
Conflict resolution: If conflicts arise between the prepaid medicine company and the affiliate, both parties must try to resolve them amicably and in good faith. If it is not possible to reach an agreement, you can resort to mediation or even go to court.
The principle of good faith implies that both the company and the affiliate must act honestly, loyally and transparently in all their interactions, respecting the rights and obligations established in the contract.
These health care companies employ several strategies to ensure that prospective enrollees are acting in good faith. Below are some of the common measures that these companies typically implement:
Background check: For example, they may conduct a background check to evaluate the financial situation and payment history of prospective members. This allows them to identify potential late payment risks and make informed decisions about accepting new enrollees.
Risk Analysis: Through risk analysis, they evaluate the likelihood that a future member will incur high medical costs. This may include evaluating age, health status, medical history, and other relevant factors that may influence health care costs.
Information requirements: they can ask future members for detailed information about their personal, work and health situation. This information allows them to evaluate the member’s suitability for the health plan offered and detect possible inconsistencies or falsehoods.
Signing of sworn statements: Future members must sign sworn statements in which they ensure that the information provided is true and complete. These affidavits may include information about health status, medical history, and other aspects relevant to the risk assessment.
Periodic reviews: Prepaid medicine companies could carry out periodic reviews of the situation of their members, through prevention programs, to ensure that they continue to comply with the requirements established in the contract. This may include reviewing changes in the member’s employment, financial or health situation that may affect his or her ability to meet contract obligations.
In summary, prepaid medicine companies implement various measures to ensure that future members act in good faith and comply with the requirements established in the contract. These measures include background checks, risk analysis, requesting detailed information, signing affidavits, and periodic reviews of the member’s situation.
Having taken all the precautions to ensure who will be accepted as a member, if the social insurance does not cover a surgery, for example, alleging bad faith, the member has the right to question this decision, present documentation and evidence that supports the medical necessity of the surgery. , negotiate with the social work and, if necessary, resort to legal resources through the action of amparo or summary judgment and consumer defense to protect their rights.
That is the successful case in which we recently obtained a ruling in favor of a member of a prepaid medicine company who had been notified of the disaffiliation and loss of coverage minutes before entering surgery alleging bad faith, in the records: AFZ c / COMPANY OF MP S/ AMPARO” Federal Court of Corrientes issued a ruling: … RESOLVED: 1). MAKE PLACE FOR THE ACTION and order to restore the plaintiff’s affiliation to the Plan… under the conditions contracted on 7/28/23. 2). IMPOSE the costs on the defeated defendant.
Each case has its special characteristics, which will be evaluated in detail in order to develop the best strategy, taking into account the type of benefit or claim to be made, for example: age of the person, state of health, etc., given that Sometimes the time that one procedure or another may take can be very relevant to preserve the life and health of the member.
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