Lawsuits against health plans grow 83% in ten years in São Paulo

In 2025, the court judged 85 actions against plans per business day, on average. From January to June 2026, 9,071 cases were judged - if the pace is maintained, the number should exceed last year's total.

"It's a clear sign that plans are increasingly free and daring to commit abuses", says Mário Scheffer, professor at USP and Geps coordinator.

There was also a discrepancy between judicialization and number of clients, since the health plan coverage rate in the state remained stable, at around 40% of the population throughout the decade.

The highest volume of lawsuits recorded in 2018, according to Scheffer, may reflect both a one-off increase in lawsuits due to readjustments and a concentrated effort by the TJ-SP to reduce the backlog of processes reaching the second instance, held back from previous years.

Fenasaúde (National Supplementary Health Federation), which represents ten large groups of private health care plan and insurance operators, states that the growth of judicialization reflects legislative changes in the list of the ANS (National Supplementary Health Agency) from 2022, especially law 14,454, which would have changed the behavior of litigation.

It also states that the sector has invested in ombudsman offices and mediation mechanisms to resolve conflicts outside the judicial sphere.

Law 14,454 treats the list of ANS procedures as exemplary, and no longer exhaustive. In practice, this means that operators may be forced

to cover treatments or procedures that are not on the list as long as there is proof of scientific effectiveness or there is a recommendation from bodies that evaluate these technologies, such as Conitec.

The law was questioned by the STF (Federal Supreme Court), which validated it in 2025, but imposed stricter criteria for the Judiciary to grant this type of coverage - such as the requirement for prior consultation with Nat-Jus (Judicial Technical Support Center), with a report or prescription from the attending physician not being sufficient.

Abramge (Brazilian Association of Health Plans), which has 135 associated operators, in a note, says that "appealing to justice is a right guaranteed to every citizen", that the debate must continue to be conducted based on technical criteria, and that "not all legal demands arise from failures in the health system".

A more detailed portrait of the reasons for the actions in the study also appears in a specific sample: with the help of artificial intelligence, Geps analyzed 631 sentences handed down by the TJ-SP in May this year.

In this sample, refusals of coverage were the most frequent reason (30.4% of cases) for actions, followed by complaints about abusive adjustments (16.6%) - together, the two themes correspond to almost half of the decisions analyzed in the period. Among the most questioned denials are refusals of high-cost medications, oncological treatments and surgical procedures.

In a case judged this year by the TJ-SP, the adjustments due to a change in age group applied to an elderly woman increased her monthly payment from R$754.11 to R$8,075.43 - an increase of more than 970%. The court classified the increase as "confiscatory in nature" and declared the abusive adjustments abusive, in addition to citing a lack of transparency in the percentages applied by the operator.

In a second case, a patient with multiple sclerosis was denied the drug ocrelizumab, sold for more than R$30,000, by the operator, on the grounds that she did not meet the administrative criteria of an ANS guideline, even though the drug had already been on the list of mandatory procedures since 2021. The court considered the refusal abusive, understanding that administrative guidelines cannot override the recommendation of the attending physician.

Other recurring reasons identified in the sample include unilateral contract terminations at the initiative of operators, deaccreditation of hospitals, maintenance of retirees and laid-off employees in corporate collective plans, retention of dependents after the death of the holder and disputes involving waiting periods, temporary partial coverage and pre-existing illnesses or injuries.

Still regarding the May sample, the results were more favorable to the consumer: 83.8% of decisions about refusing coverage and treatment served the beneficiaries fully or partially, as well as 85.7% of decisions about adjustments.

For Scheffer, judicialization is part of the business and the management of plans. "Operators know that it is the minority of consumers who can access justice, so it is worth breaking the law, denying a lot today and paying little tomorrow."

Geps makes the reservation that this is an exploratory survey, given the restricted period and the limitations of the AI tool used to classify the judgments.

The researchers state, however, that the results confirm previous Geps studies - carried out with larger samples and manual analysis of decisions - which reached similar conclusions about the most judicialized topics and the percentages of consumer success.

The study also compared the volume of actions against private plans with that of actions against the SUS (Unified Health System) in the same period. Between 2015 and 2025, the TJ-SP judged 159,015 actions against health plans, compared to 57,824 against the SUS.

Although the comparison requires caution, since the nature of the demands is different, the researchers consider that the judicialization against private plans is proportionally more significant than against the SUS. The plans serve around 40% of the São Paulo population, while the SUS covers almost 46 million inhabitants in the state.

"Many who have problems with health plans do not have their complaints resolved by the operators and the ANS, which is why they take more legal action", says Scheffer.

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