The relationship between members and social health insurance funds (obras sociales) or private health insurance companies (prepagas) frequently gives rise to disputes: premium increases considered excessive, unilateral termination of coverage, exclusions based on pre-existing conditions, challenges to the scope of coverage, delays in authorisations, and plan modifications. The legal framework — Law 23.660 and Law 23.661 for social health insurance funds; Law 26.682 for private health insurance; the Mandatory Medical Program (PMO); and resolutions of the Superintendency of Health Services (SSS) — delineates the rights and obligations of each party.
Members have several avenues of recourse: an internal claim before the insurer, a complaint to the Superintendency of Health Services (SSS), a claim before the Consumer Protection Authority (Law 24.240, particularly in relation to private health insurers), and, ultimately, judicial action (amparo proceedings or ordinary civil proceedings).
Premium increases by private health insurance companies are subject to official authorisation. Increases that exceed the authorised cap or are applied without legally required notice are contestable. Numerous collective amparo proceedings have been successfully litigated in this area.
Private health insurers may not terminate a member's coverage due to the onset or worsening of a pre-existing condition (Law 26.682, Article 10). This is a mandatory provision of public policy.
Where the plan offered covers less than the PMO or the legally mandated services, the member may claim full coverage on the basis of applicable law.
A substantial unilateral modification of the contracted service may be challengeable, particularly where it affects ongoing treatments or constitutes an abuse of right.
Coverage for spouses, children, and domestic partners. Inclusion of minors with disabilities. Dual coverage under two social health insurance funds.
The internal claim is the first step: the member ombudsman of the social health insurance fund or private insurer. Filing a claim creates a formal record and, in many cases, resolves the dispute. If not, the next steps are: a complaint to the SSS (which has sanctioning authority over social health insurance funds and, partially, over private health insurers); a claim before the Consumer Protection Authority (particularly for private health insurers, which are subject to Law 24.240); and, finally, judicial action (amparo where urgency exists; ordinary proceedings for damages claims).
Legal fees and court costs may be charged to the losing party under a costs order. In many cases, claims are resolved at the administrative level, avoiding litigation entirely.