What is the prior sworn declaration that Prepaid and Social Works request when joining?
It is a membership requirement that is regulated so that, in the event of pre-existing diseases or conditions, the Health Provider can request authorization from the Superintendence of Health Services to charge a differential fee value, on a limited and temporary basis (article 10 of Law No. 26,682 and Regulatory Decree No. 1993/11 -TO Decree No. 66/2019-).
When faced with a membership request, can the OS or Prepaga establish “deficiencies” or deny it, based on the declaration of pre-existing diseases?
In relation to “gaps” or waiting for coverage of a specific health benefit, these cannot be established if they are included in the Mandatory Medical Program (PMO). Those that are outside must be sufficiently explicit in the affiliation contract and approved by the Enforcement Authority (SSSalud).
Regarding refusal of membership, the disclosure of a pre-existing illness cannot be a reason to justify the refusal.
However, it is important to emphasize, as established by the legislation on the matter, that membership may be rejected in the event of concealment or falsification of a pre-existing disease or condition, that is, when the user acts in bad faith.
So, what is the reason why users are required to issue this affidavit?
The cause is related to revealing the sincerity of the applicant seeking affiliation, to prevent him from taking advantage of the concealment of a pre-existing illness, in order to obtain, through deception, medical coverage and treatments for said illness or condition.
The sworn statement seeks to establish the relationship with the OS or Prepaid using clear contracting rules.
In the event of a declaration of pre-existence, its characteristics will constitute the basis for the OS or Prepaid to consult the SSSalud about the amount and time of the additional fee that may be charged to the affiliate.
Can an OS or Prepaid Medicine Company set at its discretion the amount and time of the additional fee that it will charge in the event of a declaration of pre-existence?
No, it will only be the Superintendency of Health Services who can set the amount, taking into account the reported pathology. The control body will also be in charge of setting the time in which the additional fee may be collected, which may never exceed 2 years.
What should be done if membership is refused or high and disproportionate amounts of the additional fee are set?
The claim can be made at the administrative headquarters of the SSSalud; reliably notify the OS or Prepaga to stop its misconduct and at the same time raise the case in the Federal Justice, to enforce the violated rights, through the promotion of an Amparo action.
To contact Calderaro & Asociados, do so through @derechoensalud_calderaro, calling or sending a WhatsApp to (11) 6497-9732.
We thank Malu Visual Studio (Instagram @malu.visualstudio) for the photographic material
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