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Does health insurance have to cover organ transplants?

Organ transplants play a fundamental role in medicine, giving many people a second chance at life. For example, heart transplants can save patients with terminal heart failure, while skin transplants are crucial for victims of severe burns.

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However, this procedure still raises many questions. Issues related to compatibility between donor and recipient, organ availability, and the donation process itself are some of the concerns that need to be addressed. A pressing concern for patients on the waiting list for a compatible donor is whether their health insurance is obliged to cover the transplant.

The answer is yes.

The National Supplementary Health Agency (ANS) has established clear guidelines for covering vital organ transplants, such as kidney, cornea, and bone marrow. These three types of transplants are on the ANS list as minimum cover, but it is worth noting that, if there is a medical indication, other types of transplants, such as heart, lung, liver and pancreas, should also be covered.

It is the health insurer’s duty not only to offer cover for transplants, but also to ensure that there is an accredited network and hospitals qualified to carry out these procedures. When there is no accredited network or hospitals suitable for the transplant, the beneficiary has the right to request cover outside the accredited network.

This is extremely important to ensure that beneficiaries have access to the treatments they need to save lives and improve their quality of life.

What to do if your health insurance denies coverage?

Unfortunately, it is common for health insurers to deny cover for certain procedures on the grounds that they are not included in the ANS list or in the beneficiary’s policy. However, when it comes to an organ transplant, if there is a medical recommendation, the insurer is obliged to provide cover for the procedure. Any refusal is considered abusive, as it goes against the patient’s legitimate medical need.

These regulations aim to guarantee that beneficiaries have access to the vital treatments prescribed by their doctors, ensuring that financial issues do not interfere with obtaining the necessary medical care.

If the insurer insists on not carrying out the procedure, the beneficiary can lodge a complaint with the ANS. In addition, in more complex situations, it is advisable to seek legal assistance from a lawyer specializing in consumer or health law.

How can you offer the best benefits to your employees?

At Pryor Global, we offer a wide range of insurances. Our commitment is to ensure that your team has access to essential benefits for well-being and job satisfaction. We create tailor-made solutions that meet your company’s specific needs, providing peace of mind and security at every stage.

Talk to one of our experts now!

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