La obra social Apross fue condenada al pago de $ 240.574,55 (más actualizaciones e intereses), suma que deberá ser abonada a los sucesores del afiliado, en concepto de reintegro de los gastos que el paciente debió efectuar en una clínica privada que no es prestadora de Apross. Esto, debido a que la institución a la que lo había derivado la Apross no contaba con especialistas para operarlo de cáncer de esófago. Así lo resolvió la Cámara Civil, Comercial, de Familia y del Trabajo de Marcos Juárez al hacer lugar a la demanda contencioso administrativa entablada contra la Apross.
En la resolución, el vocal Jorge Namur esgrimió que, en la causa, ha quedado acreditado que “el paciente (afiliado) concurrió inicialmente a prestadores de Apross, los que no pudieron darle solución”, para atender la cirugía, “por carecer de cirujano especializado en la patología” que padecía. En efecto, la entidad prestadora recién a partir del mes de abril de 2012 comenzó a contar “con profesionales capacitados para la resolución de la patología de referencia (cáncer de esófago)” y la intervención quirúrgica en cuestión tuvo lugar “el 11 de octubre de 2011” en otra clínica.
El camarista calificó como “impropia” la posición de la Apross, que, “después de una prueba evidente que ya constaba en el expediente administrativo, solicitada a su propia instancia, negara -al contestar la demanda- la afirmación” de la demandante de que no se había podido operar en la clínica prestadora por carecer de médicos especialistas para tal patología.
Desconocimiento
En la misma dirección, el magistrado subrayó que llama la atención el hecho de que el subdirector de Prestaciones de la Apross, conforme surge de la causa, “no sabía” que la clínica prestadora “no contaba con profesionales aptos para dar solución a la patología que presentaba” el paciente. “Es decir, la Apross pretende que sus afiliados conozcan, a través de una cartilla en la web, lo que ellos desconocen, siendo receptora y depositaria de toda la documentación”, agregó el vocal, a cuyo voto se adhirieron sus pares, Graciela del Carmen Filiberti y Teresita Carmona Nadal de Miguel.
Al mismo tiempo, el camarista analizó el argumento de la Apross, según el cual el tiempo transcurrido entre el diagnóstico y la cirugía revelaba que el caso no revestía urgencia. “No es de importancia menor que se trate de un paciente del interior de la provincia, cuyo domicilio (Marcos Juárez) se encuentra a más de doscientos sesenta kilómetros de la ciudad de Córdoba. De allí que, para hacer jugar los tiempos como pretende la demandada, no es lo mismo un afiliado de capital que uno del interior, pues la provincia no termina en el Arco de Córdoba, y por ello los tiempos no son los mismos para unos que para otros cuando requieren la atención de un centro radicado en la ciudad de Córdoba, por los mayores inconvenientes que genera la lejanía”, expresó.
No obstante, el Dr. Namur precisó que, desde el diagnóstico comunicado en Marcos Juárez, pasando por todo el trámite ante la institución prestadora, que comunicó la imposibilidad de la intervención quirúrgica, hasta que esta se hace efectiva en otra institución (el 11 de octubre de 2011), “transcurrieron solo 48 días y no dos meses, como se afirma en la contestación de la demanda”.
Falta de atención adecuada
El camarista también hizo alusión a que los demandantes insistieron en todo momento en que la operación no admitía dilaciones, circunstancia que había negado la propia Apross. El vocal calificó la afirmación de la Apross como “infundada y científicamente incorrecta”, porque, “al momento de formularla, ya el paciente había fallecido por motivo de la enfermedad cuya atención requería”.
En definitiva, el tribunal concluyó que “la Apross, en su oportunidad, no asumió por un medio eficaz y en forma eficiente la atención adecuada de su afiliado, conforme a la patología que presentaba”. Por el contrario, “el paciente, ante la falta de asistencia por parte de la única institución de alta complejidad que fue acreditada en el expediente administrativo como contratada por la Apross, sometió la atención de su salud a una institución reconocida, de calidad científica comprobada, lo que aleja cualquier reproche relacionado con esta actitud, porque perseguía el objetivo de promover la salud, de prevenir la enfermedad, de recuperar y rehabilitar la situación de salud, de acuerdo con una atención médica especializada tanto profesional como institucional». Por lo tanto, esa actitud adoptada «no puede ser motivo de reproche para descalificarla legalmente».
Como consecuencia, tras declarar la nulidad de dos resoluciones de la Apross contrarias a planteos de los demandantes, el tribunal consideró que se había “vulnerado un derecho subjetivo del administrado”, por lo que correspondía hacer lugar a la demanda y condenar a la Apross a que abonara la suma de 240.574,55 pesos (calculados al 15 de febrero de 2012), desde la fecha en que se promovió el reclamo administrativo de reintegro. Esto, por cuanto los montos no han sido cuestionados por la demandada y los códigos de reintegro han sido admitidos por los mismos informes internos de Apross. El importe deberá hacerse efectivo a partir de los cuatro meses (calendario) de que quede firme y consentida la resolución jurisdiccional que apruebe la planilla con la liquidación definitiva.
Fecha: 1 de diciembre de 2016.
Causa: «P. de B., A. y otros c/Administración Provincial de Seguros de Salud (Apross) – Demanda contencioso administrativa”.
Fuente: www.justiciacordoba.gob.ar
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