Complete ANS Complaint Guide: How to Fight a Health Insurance Denial in Brazil

If your Brazilian health insurer has denied a claim, refused to authorize a procedure, or violated your rights as a plano de saúde beneficiary, the ANS (Agência Nacional de Saúde Suplementar) is your primary regulatory ally. This guide walks through every step of the ANS complaint process — from initial filing to formal investigation, PROCON escalation, and court action.

What Is ANS?

ANS is the federal agency responsible for regulating Brazil's supplementary health sector — all private health plans (planos de saúde) sold in Brazil. Every insurer offering health coverage must be ANS-registered and comply with ANS rules, including the mandatory ROL de Procedimentos (coverage list). ANS has enforcement power: it can fine insurers, suspend sales, and order immediate coverage of denied procedures.

Before Filing: Internal Ouvidoria First

ANS requires beneficiaries to attempt resolution through the insurer's Ouvidoria (internal ombudsman) before escalating. This is not merely a formality — Ouvidoria resolution avoids regulatory timelines and often resolves disputes faster.

How to reach the Ouvidoria:

• Call your insurer's specific Ouvidoria number (distinct from general customer service)
• Send a written complaint via registered mail (carta com AR) for documentation
• Use the insurer's online Ouvidoria portal if available

What to document: complaint date, protocol number, the name of the representative you spoke with, and the exact grounds for the denial (per the insurer's written denial letter).

The Ouvidoria must respond within 5 business days for non-urgent matters and 3 hours for urgent/emergency situations per ANS Resolution RN 465.

Step 1: File with ANS — The NIP Process

If the Ouvidoria does not resolve your complaint, file directly with ANS. You have two options:

Online portal: Register at ans.gov.br and file through the "Solicitação de Análise de Reclamação" module. Upload your denial letter, medical records, physician justification, and Ouvidoria response.

Disque-ANS: Call 0800-701-9656 (free, Monday–Friday). A representative will open a complaint and provide your protocol number.

When ANS receives your complaint, it opens a NIP — Notificação de Investigação Preliminar. This formally notifies your insurer that a regulatory investigation has begun.

The 7-Day Mediation Window

After the NIP is issued, ANS enters a 7-business-day mediation window. During this period:

1. ANS contacts your insurer directly
2. The insurer must provide ANS with its justification for the denial
3. ANS mediators assess whether the denial complies with ANS rules
4. If the denial violates ANS regulations (particularly ROL coverage rules), ANS can order immediate reversal

A substantial percentage of denials are reversed during this mediation window — often because the insurer recognizes the exposure of defending an indefensible position before a regulator.

What Happens After Mediation

If mediation does not resolve the dispute, ANS proceeds to formal investigation. Possible outcomes include:

• Notificação de Infração (NI): ANS issues a formal infraction notice against the insurer
• Auto de Infração: A formal penalty proceeding that can result in fines of up to R$1 million
• Medida Cautelar: Emergency injunctive order requiring the insurer to provide coverage immediately (available in life-threatening situations)

ANS publishes insurer complaint ratios publicly, which creates reputational pressure. High complaint rates can lead to ANS suspending an insurer's right to sell new policies.

Key ANS Resolutions to Reference

When filing your complaint, cite these ANS resolutions relevant to your situation:

• RN 465 (2021): Timeframes for authorization responses — 5 days elective, 3 hours urgent
• RN 566 (2022): Rules on coparticipação (cost-sharing) limits
• RN 395 (2016): Network adequacy requirements
• ROL de Procedimentos: The current mandatory coverage list (updated periodically)

Step 2: PROCON — Consumer Code Escalation

PROCON (Programa de Proteção e Defesa do Consumidor) operates in every Brazilian state and covers health insurance disputes under the Código de Defesa do Consumidor (Lei 8.078/1990). File at your state's PROCON:

• PROCON-SP: procon.sp.gov.br
• PROCON-RJ: procon.rj.gov.br
• PROCON Federal: consumidor.gov.br (national platform)

PROCON can impose fines for abusive practices and mediate disputes independently of ANS.

SUSEP: A Note on Supplementary Products

SUSEP (Superintendência de Seguros Privados) regulates insurance products that are not ANS-covered planos de saúde — this includes certain life insurance riders with medical benefits, dental-only plans sold under insurance licenses, and international health insurance products. If your product is SUSEP-regulated (not ANS), file with SUSEP at susep.gov.br rather than ANS.

Step 3: Juizados Especiais Cíveis (JEC)

For disputes up to 40 minimum wages (~R$60,000), Brazil's small claims courts are an accessible option. No attorney is required. Bring:

• Your written denial letter
• Medical records and physician justification
• ANS complaint records and outcome
• Your plano de saúde contract
• ROL documentation showing your procedure is covered

Brazilian courts have consistently ruled in favor of beneficiaries in cases involving ROL-listed procedures.

Fight Back With ClaimBack

The ANS system is powerful but requires careful documentation and procedural compliance. ClaimBack helps you structure your appeal and complaint with the right regulatory references from day one.

Start your free appeal at ClaimBack

Related Reading

• How to Write an Insurance Appeal Letter
• Internal vs. External Insurance Appeal: What's the Difference?
• Common Reasons Insurance Claims Are Denied