The Santiago Court of Appeals accepted a protection appeal and ordered Isapre Life Three Covering bariatric surgery Which was medically recommended by your colleague.
In a unanimous decision, the Second Chamber of the Court of Appeal established Insurer’s arbitrary act in denying coverage on the grounds that it would be an aesthetic treatmentIgnoring the medical recommendation, for what reason ordered him to cover the intervention in terms and for an amount consistent with the contracted plan.
The ruling remarked that “despite the merit that the medical procedure the Isapre was subjected to by the appellant Medical reports have been tampered with Dated September 29, 2021 (…). In the said document, the surgeon marcos berry S., gives an account of the health status of the appellant as of July 4, 2021 and states that the patient is in consultation with the multidisciplinary obesity and nutrition team Las Condes Clinic and from its evaluation it is possible to conclude that presents with severe obesity, asthma, arterial hypertension, insulin resistance and sleep apnea”,
The resolution states that “due to the diagnosis presented by the patient, it is connected Decreased long-term survival and quality of lifeIt is believed Good candidates for laparoscopic sleeve gastrectomy, as a treatment for their obesity and associated co-morbidities. As indicated, the said professional emphasizes that, based on accepted national and international consensus, There are no aesthetic purposes in this surgery nor for any other purpose not related to the establishment of his health”.
Isapre justified his refusal by saying that the patient’s “body mass index is less than 40 and there is no evidence to support that he has had the failure of any previous medical treatment (non-surgical) to lose weight” , nor is there any support for treatment for those diagnosed with high blood pressure and insulin resistance.
However, for the appellate court: Isapre’s defense, “appellant was confronted with the medical report, lacking justification since, unlike Isapre Vida Tres, the medical report reviewed in section nine states that the laboratory test , also requested the study and evaluation of a nutritionist, psychologist and kinesiologist at the Complementary Center for Nutrition and Bariatric Surgery, who allows us to exclude that it was an intervention of an aesthetic nature or ornamentation,
“It is precisely the lack of justification that becomes Maniac and consequently arbitraryThe insurer’s refusal to provide its colleague with the required coverage, which as a logical consequence leads to the fact that the constitutional action filed should have prospered,” the ruling concluded.