Obesity treatment in clinic can be paid for by health insurance

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Health plans are obliged to pay for the hospitalization of morbidly obese patients in hospitals or clinics specialized in weight loss, if this is recommended by the doctor, even if there is no contractual provision for such coverage. This is the understanding of the 3rd Panel of the Superior Court of Justice.


At the trial, the panel rejected the request to modify the ruling that forced the health plan to pay for weight loss treatment for users with morbid obesity, grade III, in a specialized clinic. Unanimously, however, the panel partially accepted the appeal to exclude compensation for moral damages to the patient from the conviction.

“If there is a medical indication for the B2B Lead treatment of morbid or severe obesity through hospitalization in a weight loss clinic, it is not up to the operator to deny coverage on the grounds that the treatment would not be suitable for the patient, or that there would be no contractual provision, as such Therapy, as a last resort, is fundamental to the user's survival, including the reduction of complications and diseases resulting from it, and is not a simple aesthetic or weight-loss procedure”, stated the rapporteur of the operator's appeal, Minister Villas Bôas Cueva.

In the action, the patient asked for the cost of the treatment, claiming the failure of other previously attempted therapies. He further stated that he could not undergo bariatric surgery due to having several illnesses, which meant his situation was at risk of death.

According to Villas Bôas Cueva, the legislation is clear in indicating that the treatment of morbid obesity is mandatory coverage by health plans, under the terms of article 10, caput, of Law 9,656/1998.

The rapporteur highlighted that, when there is a medical indication, treatment can be carried out with hospitalization in medical establishments, such as hospitals and clinics, even though, as a rule, operators prefer to offer users multidisciplinary outpatient treatments or surgical indications, such as bariatric surgery. .

Medical orders
Villas Bôas Cueva stressed that the jurisprudence of the STJ is firm in the sense that the doctor or qualified professional – and not the health plan – is the one who establishes, in the search for a cure, the therapeutic guidance to be given to the user suffering from illness.

The minister highlighted that the legal restriction on health insurance funding for weight loss treatments is restricted only to treatments of an aesthetic or rejuvenating nature, mainly those carried out in SPAs, rest clinics or hydromineral resorts.



“Thus, even if the Consumer Protection Code (CDC) does not apply to self-management entities, the health plan contractual clause that excludes obesity treatment in a weight loss clinic from coverage proves to be abusive based on articles 423 and 424 of the Civil Code, since, due to the nature of the deal signed, there are situations in which hospitalization in such an establishment is highly necessary for the recovery of the morbidly obese person, even more so if outpatient treatments fail and bariatric surgery is not recommended”, explained the minister.