{"id":901197,"date":"2026-11-04T13:00:00","date_gmt":"2026-11-04T16:00:00","guid":{"rendered":"https:\/\/lexflowcrm.com.br\/blog\/?p=901197"},"modified":"2026-10-15T19:22:13","modified_gmt":"2026-10-15T22:22:13","slug":"carencia-do-plano-de-saude-urgencia-tjsc","status":"publish","type":"post","link":"https:\/\/lexflowcrm.com.br\/blog\/carencia-do-plano-de-saude-urgencia-tjsc\/","title":{"rendered":"Car\u00eancia do plano de sa\u00fade: Justi\u00e7a de SC manda reembolsar cirurgia de urg\u00eancia e indenizar paciente"},"content":{"rendered":"

A 3\u00aa Vara C\u00edvel de Joinville (SC) condenou uma operadora que recusou a cirurgia de urg\u00eancia de um cliente com base na car\u00eancia do plano de sa\u00fade. Pela senten\u00e7a, a empresa ter\u00e1 de devolver os R$ 25 mil que o paciente pagou pelo procedimento e indeniz\u00e1-lo em R$ 10 mil por danos morais. Trata-se de decis\u00e3o de primeira inst\u00e2ncia, noticiada pelo Tribunal de Justi\u00e7a de Santa Catarina (TJSC) em 14 de outubro de 2026.<\/p>\n

O caso: apendicite onze dias depois da contrata\u00e7\u00e3o<\/h2>\n

O consumidor aderiu ao plano em julho de 2025. Onze dias depois, deu entrada no hospital com fortes dores na barriga. O diagn\u00f3stico apontou apendicite aguda com peritonite generalizada, e a equipe m\u00e9dica indicou opera\u00e7\u00e3o imediata.<\/p>\n

No entanto, a operadora negou a cobertura da interna\u00e7\u00e3o e da cirurgia. De acordo com ela, o contrato previa 180 dias de car\u00eancia para esses procedimentos. Sem a cobertura, restavam duas op\u00e7\u00f5es: pagar R$ 25 mil pela cirurgia ou ser transferido para a rede p\u00fablica. Para pagar a cirurgia, ele usou o cart\u00e3o de cr\u00e9dito de outra pessoa. O prontu\u00e1rio registrou o procedimento, uma laparotomia exploradora com ileocolectomia, como cirurgia de urg\u00eancia.<\/p>\n

Na Justi\u00e7a, a operadora defendeu que a recusa era regular. Tamb\u00e9m argumentou que, enquanto corre a car\u00eancia, o atendimento de emerg\u00eancia fica restrito \u00e0s primeiras 12 horas.<\/p>\n

O que o juiz decidiu<\/h2>\n

O magistrado, por\u00e9m, lembrou que a lei fixa em 24 horas a car\u00eancia m\u00e1xima para casos de urg\u00eancia e emerg\u00eancia. A regra est\u00e1 no artigo 12, inciso V, al\u00ednea “c”, da Lei 9.656\/1998, que trata dos planos de sa\u00fade. Uma vez que o paciente procurou o hospital onze dias depois de contratar, esse prazo j\u00e1 tinha passado.<\/p>\n

Os pr\u00f3prios documentos do hospital mostravam a suspeita de apendicite e a indica\u00e7\u00e3o de cirurgia urgente. Para o juiz, restringir a cobertura \u00e0s primeiras 12 horas esvaziaria a finalidade do contrato e deixaria o consumidor em desvantagem excessiva.<\/p>\n

Al\u00e9m disso, o juiz reconheceu o dano moral. Segundo a senten\u00e7a, o caso passou do simples descumprimento de contrato, porque o paciente teve de recorrer ao dinheiro de terceiros para ser operado.<\/p>\n

A decis\u00e3o segue a mesma linha da S\u00famula 597 do Superior Tribunal de Justi\u00e7a (STJ), que considera abusiva a cl\u00e1usula de car\u00eancia em urg\u00eancia ou emerg\u00eancia depois de passadas 24 horas da contrata\u00e7\u00e3o.<\/p>\n

O que muda na pr\u00e1tica em disputas sobre car\u00eancia do plano de sa\u00fade<\/h2>\n

A senten\u00e7a trata de um caso individual, mas re\u00fane pontos \u00fateis para quem atende pacientes ou operadoras. Alguns cuidados:<\/p>\n

    \n
  1. Conte o prazo desde a contrata\u00e7\u00e3o.<\/strong> Passadas 24 horas, a car\u00eancia n\u00e3o pode barrar o atendimento de urg\u00eancia ou emerg\u00eancia. Confira a data de in\u00edcio do contrato, a do atendimento e o tipo de cobertura contratada.<\/li>\n
  2. Garanta a prova m\u00e9dica.<\/strong> A lei define emerg\u00eancia como situa\u00e7\u00e3o com risco imediato de vida ou de les\u00f5es irrepar\u00e1veis, caracterizada em declara\u00e7\u00e3o do m\u00e9dico assistente (artigo 35-C). Pe\u00e7a essa declara\u00e7\u00e3o e o prontu\u00e1rio que classifica o caso.<\/li>\n
  3. Registre a negativa.<\/strong> Oriente o cliente a pedir a recusa por escrito, com o motivo, e a anotar protocolos e nomes de setores contatados.<\/li>\n
  4. Guarde a prova do pagamento.<\/strong> Comprovantes, inclusive de cart\u00e3o de terceiro, sustentam o reembolso e ajudam a mostrar o abalo sofrido.<\/li>\n
  5. Revise cl\u00e1usulas, se o cliente for a operadora.<\/strong> Afinal, o juiz viu na limita\u00e7\u00e3o a 12 horas uma fonte de desvantagem excessiva. Vale reavaliar contratos e roteiros de atendimento.<\/li>\n<\/ol>\n

    Orienta\u00e7\u00f5es de atendimento e sigilo para casos com informa\u00e7\u00f5es m\u00e9dicas est\u00e3o no texto sobre clientes na advocacia de sa\u00fade<\/a>.<\/p>\n

    Discuss\u00f5es sobre car\u00eancia do plano de sa\u00fade costumam come\u00e7ar com urg\u00eancia e documentos espalhados entre hospital, operadora e fam\u00edlia. Por isso, conv\u00e9m montar uma linha do tempo com a data da contrata\u00e7\u00e3o, a do atendimento e a da negativa, e guardar por escrito as orienta\u00e7\u00f5es passadas ao cliente sobre provas e prazos.<\/p>\n

    Fonte: Plano de sa\u00fade deve devolver valor pago por cirurgia de urg\u00eancia e indenizar paciente<\/a>, publicada pelo TJSC em 14\/10\/2026.<\/p>\n

    Agende uma demonstra\u00e7\u00e3o do LexFlow<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

    Operadora negou cirurgia por apendicite alegando car\u00eancia do plano de sa\u00fade; vara de Joinville aplicou o limite de 24 horas e mandou reembolsar R$ 25 mil.<\/p>\n","protected":false},"author":4,"featured_media":901322,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[511],"tags":[520,393,607,645,655],"class_list":["post-901197","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-noticias-juridicas","tag-carencia-do-plano-de-saude","tag-direito-do-consumidor","tag-plano-de-saude","tag-tjsc","tag-urgencia-e-emergencia"],"yoast_head":"\nCar\u00eancia do plano de sa\u00fade: 24 horas na urg\u00eancia<\/title>\n<meta name=\"description\" content=\"Operadora negou cirurgia por apendicite alegando car\u00eancia do plano de sa\u00fade; vara de Joinville aplicou o limite de 24 horas e mandou reembolsar R$ 25 mil.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/lexflowcrm.com.br\/blog\/carencia-do-plano-de-saude-urgencia-tjsc\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Car\u00eancia do plano de sa\u00fade: 24 horas na urg\u00eancia\" \/>\n<meta property=\"og:description\" content=\"Operadora negou cirurgia por apendicite alegando car\u00eancia do plano de sa\u00fade; 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