Ordenan a una prepaga solventar un “by pass” gástrico a una afiliada con obesidad severa

Una empresa de medicina prepaga deberá solventar, en forma integral, los gastos que genere una cirugía bariátrica, mediante “by pass” gástrico, prescripta a una afiliada que tiene un diagnóstico de obesidad severa, aunque el índice de masa corporal (IMC) de la paciente no alcanza los 40 kilogramos por metro cuadrado, que establece la normativa vigente para la cobertura de tales intervenciones quirúrgicas.

La jueza de Control y Faltas de Villa María, Edith Lezama de Pereyra, hizo lugar a la acción de amparo formulada por la afiliada por entender que ese requisito “no es excluyente”, puesto que dicha cirugía también se indica en aquellos pacientes que poseen un IMC igual a 35 kg/m2 “y poseen asociada alguna enfermedad secundaria a su estado de obesidad”, tales como la diabetes, la apnea del sueño o el hígado graso, entre otras.

En este sentido, la paciente acreditó en el expediente que inició un tratamiento contra la obesidad cuando tenía un IMC de 40,6 kg/m2, que merced a la realización de actividad física y el cambio de pautas alimentarias logró reducirlo a 36,51 kg/m2; y que, desde 2010, padece diabetes tipo II (es decir, no es insulino dependiente) y, desde 2016, sufre apnea del sueño. En base a este cuadro, los médicos que la trataban le prescribieron una cirugía bariátrica, mediante by pass gastroyeyunal, por videolaparoscopía.

Tratamiento ininterrumpido 

Otra de las objeciones que formuló la empresa de medicina prepaga para la cobertura total de la intervención quirúrgica fue que la afiliada no había cumplido el requisito de realizar tratamiento para bajar de peso, en forma ininterrumpida, durante por lo menos 24 meses.

En este sentido, la magistrada señaló que la paciente se sometió a un tratamiento ininterrumpido por su obesidad, desde julio de 2014: en una primera etapa, se atendió en la Clínica San Martín de Villa María; mientras que, a partir de junio de 2016, se cambió al Sanatorio Allende, de la ciudad de Córdoba.

“Es decir que a la fecha de presentación de esta demanda (enero de 2017), la paciente llevaba más de dos años de tratamiento ininterrumpido para tratar de bajar de peso, obteniendo un resultado que los especialistas calificaron de no satisfactorio, por lo que aconsejaron la realización de cirugía bariátrica”, sintetizó la magistrada.

En definitiva, la jueza Lezama de Pereyra hizo lugar a la acción de amparo y ordenó a la empresa de medicina prepaga, a prestar a su afiliada una cobertura integral de la cirugía bariátrica, mediante by pass gastroyeyunal, por videolaparoscopía, como así también los tratamientos, las prácticas, los servicios y los insumos que para ello sean requeridos, pre y post quirúrgicos, “con el mismo alcance que el establecido para los casos de personas con IMC igual o mayor a 40 Kg/m2, en la oportunidad y condiciones clínicas que el equipo médico tratante determine”. La resolución fue apelada y, actualmente, está radicada en la Cámara en lo Criminal y Correccional de Villa María.

Causa: “P. A., Y. G. c/ Asociación Mutual Sancor Salud Grupo de Medicina Prepaga – Amparo”
Fecha: 14 de junio de 2017

Fuente: www.justiciacordoba.gob.ar

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