Through Resolution No. 2400/2023, published on 11/29/2023 in the National Official Gazette (the “Resolution”), the Superintendence of Health Services approved the minimum mandatory clauses, indicated in its annex, to be included in the contracts for integral coverage plans to be entered into between Prepaid Medicine Entities (“PMEs”) and users.
Clauses included in these contracts cannot contradict the provisions set forth in the Resolution’s annex, therefore, PMEs must adapt their templates of contracts offered to the general public, in order to be aligned with the provisions established in the Resolution. Notwithstanding the foregoing, these minimum clauses will also be applicable to contracts currently in force.
The annex to the Resolution regulates several areas related to the terms and conditions of coverage plan contracts, including, among others, the following: (i) the benefit coverage, (ii) the affidavit of health and pre-existences, (iii) the prescription of medications, (iv) emergency benefits; (v) the right of equivalence; (vi) the value of the premium in general and depending on age ranges; (vii) claims in case of non-compliance by PMEs; (viii) the termination of the contract by users’ convenience or by decision of the PMEs.
The Resolution further establishes the right of PMEs to request an affidavit of health from the users to be affiliated and the right to terminate the affiliation for misrepresentation of the affidavit. Said declaration serves as an instrument to consider the existence of pre-existing conditions, and in case the user does not act in good faith, PMEs may withdraw the user’s affiliation. This shall be verified if the user: (a) omitted to report a pre-existing condition or disease in the affidavit; and (b) knew about the pre-existing condition or disease.
Finally, the Resolution orders that, within 90 days of its entry into force, PMEs must include in their institutional websites direct access to the templates of contracts of the plans they offer. Likewise, they must place printed copies at their commercialization premises and, once the affiliation contract has been executed, a copy will be delivered and/or the complete contractual documentation will be sent to them by e-mail.
By María Morena del Río, Fernando Martinez Zuviria and Salvador Blanco.
