A OUVIDORIA E SUA CONTRIBUIÇÃO NA SAÚDE SUPLEMENTAR

A RN 323/13 DA ANS

Abstract

One of the most relevant innovations that we need to experience is the ability to communicate efficiently between citizens / consumers and contemporary organizations and thus mitigate conflicts. Reflections on the role of the Ombudsman's Office may represent an opportunity to build an evolutionary line in this communication in search of better quality consumer relations, respecting rights and contributing as a management tool. Especially in Private Health Insurance and Plans, there are challenges to be overcome so that the Ombudsman's offices are more effective in the execution of public policies, but their performance can reinforce a place of participation, communication and mediation in a democratic process, resulting in the enhancement of citizenship. In order to contribute to the theoretical debate, the purpose of this project was to analyze the process of construction and performance of the Ombudsman in Private Health Insurance and Plans, which was demanded by Normative Resolution-RN 323/13 of the National Regulatory Agency for Private Health Insurance and Plans-ANS, and to understand the challenges, potential and limitations for the Ombudsman to acquire greater relevance for private health company. From analysis of literature, documents, reports and qualitative interviews with representatives of civil society, ANS, in addition to Ombudsmen working in Private Health Insurance and Plans, we understand that the Ombudsman would conceptually have the institutional role of representing the private health insurance beneficiary and seeking to adjust interests divergent in the search for conflict reduction. However, despite the advances brought by the Legislation, in practice the private health insurance beneficiary does not seem to feel represented by the Ombudsman and still frequently uses other places of representation such as the Judiciary, ANS or consumer protection entities when it needs to speak up. There is an environment prone to conflict in Private Health Insurance and Plans in Brazil that has sensitized the Judiciary, the Public Ministry, private health company, associations representing the private sector in the area of health, ANS and researchers. These conflicts have the most different motivations on the part of private health insurance beneficiary: authorization of procedures, high-cost exams, hospitalizations, monthly price adjustments, among others. Research has also shown that the Ombudsman are seen as good interlocutors with consumer protection entities, but find it difficult to evidence and prevent conflicts within the private health company of which they are a part. In the end, this project offers as a product, a set of recommendations designed for private health company and ANS in the search for good practices for better service to civil society, the result of a guideline based on research, experience and knowledge of the proposed theme in what it says respect to the Ombudsman and Private Health Insurance and Plans.