Case 52/2011

The appellant, joined by his spouse and children, filed suit against defendant Catholic Workers Circle of Uruguay, an affiliated collective medical assistance institution, to recover for loss of earning capacity and moral damages. The appellant’s doctor (co-defendant) at Catholic Workers Circle had diagnosed the appellant with a benign brain tumor and prescribed radiation therapy in conjunction with the drug “temozolomide,” but had refused to provide care until the appellant paid for his treatment. The appellant claimed he was consequently forced to purchase the drug in Buenos Aires at a lower price and receive consultation from specialists there. The defendants countered that their prescription was appropriate and denied responsibility for refusing to give treatment, stating that the institution’s mutual coverage did not include the prescribed drug.

The appellant’s claim was dismissed by the Legal Court of First Instance in Civil Matters, 18th District without special costs. On appeal, the appellant argued that under Decree No. 614/006, Catholic Workers Circle was liable for delivery of a drug until a decision about how to finance such drug was reached. Thus, the defendant had breached its service agreement and was liable for refusing to supply the medication. The appellant also claimed that another Catholic Workers Circle doctor who joined in the decision to refuse treatment (co-defendant) acted imprudently, negligently, and recklessly.

The Court recognized a universal right to health and held that the State of Uruguay was compelled by law to “protect and optimize this right, seeking the physical, moral, and social improvement of all the people to the highest possible standard.” In this context, the Court determined that the executive Decree No. 265/006 (which approved the list of drugs to be provided to patients regardless of their economic resources and included the drug in question) was applicable and could aid the interpretation of Decree No. 614/006 raised by the appellant.

The Court held that the appellant had incorrectly interpreted No. 265/006 and thus overextended the responsibilities owed by the defendant to him.  Decree No. 256/006 stated that the listed drugs should be provided by insurance institutions “as soon as the protocols related to these drugs are established and arrangements for national financing of the drugs are defined.” At the time that the defendants prescribed temozolomide for the plaintiff, the drug’s protocol and financing structure had not been approved.  Further, Decree No. 614/006 did not mandate that institutions should provide its affiliates with “whatever drug is included in the Therapeutic Drug Form, without exception.” Therefore, it was not reasonable for the appellant to assume that the mutual insurance should have been responsible for providing temozolomide before the drugs protocols and national financing had been established. The Court affirmed the lower court’s dismissal and denied additional costs for the defendants.

The Court similarly dismissed the appellant’s claim against the co-defendant for reckless and imprudent conduct, noting that the appellant admitted that the prescription was appropriate, that he had not requested an alternative medication, and that the treatment had been successful.

”From the reading and interpretation of the relevant provisions, it appears that ‘every person has the right to health, understood as the enjoyment of the highest level of physical, mental, and social wellbeing’ and it is clear that it is the State that is compelled to protect and optimize this right, seeking the physical, moral, and social improvement of all the people to the highest standard possible.

In order to achieve this, the State must not only refrain from harming the health of the population and prevent others from malicious action, but also seek the extension of health services to all, and particularly to the most vulnerable groups, and the provision of free of charge means of prevention, and care to indigents or to people with limited resources. Thus, it appears that the State is responsible for designing public health policies and carrying them out by making good legal standards of superior force, expressed as rules, principles, and guidelines.” Para III

“De la lectura e interpretación de las disposiciones respectivas surge que “toda persona tiene derecho a la salud, entendida como el disfrute del más alto nivel de bienestar físico, mental y social” y queda claro que es el Estado quien resulta obligado a defender y optimizar ese derecho, procurando el perfeccionamiento físico, moral y social de todos los habitantes al nivel más alto que sea posible.

Para lograrlo no sólo debe abstenerse de causar daños a la salud de la población y evitar que otros los causen, sino que debe procurar la extensión a todos, particularmente a los grupos más vulnerables, de los servicios sanitarios y proporcionar gratuitamente a indigentes o personas carentes de recursos suficientes, medios de prevención y asistencia. De ese modo, resulta que el Estado es el encargado de diseñar las políticas públicas de salud y de llevarlas adelante, cumpliendo exigencias normativas de rango superior, expresadas como reglas, principios y directrices” [Sección III]

“…it does not follow that, against the provision of Decree No. 265/007 that is said to apply, the health care institutions should provide its affiliates with whatever drug is included in the Therapeutic Drug Form, without exception. Rather, a more reasonable interpretation indicates that, if the compulsory compliance with the provisions of Decree 265/006 was ratified…the mandatory current health regulations apply and, to that end, drugs on the lists cannot be denied. It is not reasonable to interpret that the Advisory Commission requirement to establish protocols for the use and method of financing of the drugs included in Annex II is suppressed, putting the Mutual temporarily in charge of providing them.” [Section IV]

“ A juicio de los integrantes de este Tribunal –quediscrepan con los apelantes y también con lo que al respectoso stiene el homólogo de segundoturno (TAC 2º Sent.159/2008 considerando IV- no se infierede allíque, contrariando lo dispuesto por el Decreto Nº265/006 que se dice aplicar, las instituciones de asistencia médica deban suministrar a susafiliados cualesquiera de los medicamentos incluidos en el FormularioTécnicoTerapéutico, sin excepción alguna. Antes bien una interpretación razonable indica que, si se ratifica la obligatoriedad de cumplir lo dispuestopor el Decreto Nº265/006, ello implica suministrar los medicamentos en las condicione sallí indicadas, sin hacer excepciones. Vale decir que rige la obligatoriedad de la normativa sanitaria vigente y, porende, no pueden negarse medicamentos incluidos en los listados. No es razonable interpreter que suprime la exigencia de que la Comisión Asesora establezca los protocolos de uso y forma de financiación de los incluido en el anexo II, poniendo transitoriamente de cargo de las mutualistas proporcionarlos.” [Sección IV]