Region: Americas
Year:
Court: Constitutional Court [Corte Constitucional]
Health Topics: Chronic and noncommunicable diseases, Health care and health services, Health systems and financing, HIV/AIDS, Medicines
Human Rights: Right to health, Right to life, Right to social security
Jose Vicente Moreno, the plaintiff, was affiliated with the health promoting entity E.P.S. of the I.S.S. del Valle (“E.P.S of I.S.S.”). Due E.P.S. of I.S.S.’s failure to provide medical services that the plaintiff required for the treatment of a catastrophic illness, he filed an transfer request before the health promoting entity Comfenalco E.P.S. (“E.P.S. Comfenalco”), arguing that, under Article 153 of Act 100 of 1993 (“Article 153”), he enjoyed a right to “free choice” of health care providers. The plaintiff obtained a favorable decision on the writ for constitutional protection against the E.P.S. of I.S.S.. However, despite multiple requests and attempts on behalf of the plaintiff to obtain the transfer to E.P.S. Comfenalco, the latter repeatedly denied the transfer.
The plaintiff filed a writ for constitutional protection against E.P.S. Comfenalco, arguing that the entity’s behavior was contrary to the spirit of Act 100 of 1993 and to the freedom that individuals enjoyed to choose their health promotion organization. The Ninth Municipal Criminal Judge of Cali rejected the constitutional rights claim, holding that, that although the right to health was considered to be a fundamental right, E.P.S. Comfenalco’s decision adhered to the strict guidelines established by the National Board of Health and Social Security in the Agreement 000245 of January 31 of 2003 (the “Agreement”)(which provided for a one time redistribution of high cost patients, to occur before June 30,2003).
The plaintiff appealed but the Fifteenth Criminal Judge of the Circuit of Cali confirmed the lower court’s decision. In this instance, the judge considered that if a violation of the plaintiff’s rights had occurred, the only responsible entity was the E.P.S. of I.S.S., and not E.P.S. Comfanalco. However, the appeals court judge also determined that although the plaintiff had the right to transfer to another health promoting entity under Article 153, the E.P.S of I.S.S. had not violated any fundamental right.
The Court noted that the right to "free choice" was a basic feature of the General Social Security System; however, such right was limited by certain conditions and requirements. First, the right to choose a health promoting entity could be used only once a year, and secondly, when a person had obtained a high-cost treatment such person must remain for at least two years after the treatment had been finalized with the same health promotion entity. However, where an affected person could demonstrate his current health promoting entity had been providing poor health services, he would not have to comply with the above requirements.
The plaintiff noted that, due to the inefficient manner of the medical services provided by E.P.S of I.S.S. and its failure to provide medicines to the plaintiff, the plaintiff had filed a writ for protection of constitutional rights against E.P.S of I.S.S. Even when the court issued the requested writ, the quality of the health services provided by E.P.S of I.S.S. did not improve, thus prompting the plaintiff’s request to transfer to another health promoting entity.
The Court determined that, considering that the plaintiff‘s continued problems with E.P.S. of I.S.S., E.P.S. Comfenalco should not demand that plaintiff comply with the condition requiring him to remain in the initially chosen health promoting entity for a two-year period. Such condition did not apply where the transfer was justified by the deficient or poor rendering of the health service. As E.P.S. Comfenalco recognized the problems that the plaintiff had had with E.P.S. of I.S.S., the factual and legal premises had been established in order to justify the transfer.
Thus, the Court held that E.P.S. Comfenalco’s refusal to the plaintiff’s transfer not only failed to acknowledge the freedom that he enjoyed to choose a health promotion entity that would render him the medical services that he urgently required, but also impeded his right to effective access to the health system.
In accordance with the guidelines provided in the Agreement, whose objective was justified by the need to guarantee the economic equilibrium of the General Social Security System and the ideal and continuous rendering of the service, the Court ordered that E.P.S. Comfenalco accept the request to transfer. In view of the high costs which the E.P.S. Comfenalco would have to assume to continue with the plaintiff’s treatment, the Court further ordered that E.P.S. Comfenalco would be able to demand from the E.P.S. of I.S.S., the joint financing of the treatment in the terms. Accordingly, the Court reversed the lower courts’ rulings and granted the plaintiff’s claim for a violation of his right of access to social security in connection with life and health.
“Within the legal framework developed by Act 100 of 1993, and according to the general principles established in the Political Constitution, article 153 regulates the special principles governing the General Health Social Security System. One of such principles is the “free choice” one, by virtue of which the participation of different entities offering the administration and provision of health services is allowed, which ensures users’ freedom to choose between the health promotion organizations and the health service provider institutions, according to the service supply conditions with which, through said principle, the affiliates’ right to SGSSS is guaranteed in order to freely choose the entity that will be responsible for assisting his/her health requirements.” Pages 7-8.
“En el marco jurídico desarrollado por la Ley 100 de 1993, y de acuerdo con los principios generales consagrados en la Constitución Política, el artículo 153 se ocupa de regular los principios especiales que rigen el Sistema General de Seguridad Social en Salud. Uno de tales principios es el de la “libre escogencia”, en virtud del cual se permite la participación de diferentes entidades que ofrezcan la administración y prestación de los servicios de salud, y se asegura a los usuarios libertad en la escogencia entre las entidades promotoras de salud y las instituciones prestadoras de los servicios de salud, de acuerdo con las condiciones de oferta de servicios; con lo cual, a través de dicho principio se garantiza el derecho de los afiliados al SGSSS de elegir libremente la entidad que estará a cargo de atender sus requerimientos en salud.” Pagina 10-11.
“[T]he cited norm establishes two conditions for the right to “freely choose”. Firstly, numeral four (4°) establishes that the affiliates of the General Social Security System exercise their right to “choose freely “once a year; term which shall be counted as of the date on which they were affiliated to the SGSSS. Secondly, numeral nine (9°) imposes another limitation to the right of “freedom of choice”, which consists in the obligation of staying at least two (2) years in the same health promotion organization, when being subjected to a treatment classified as of high cost, a term which will start tolling “after the corresponding treatment has finalized before the health promotion entity.” Notwithstanding, even though the exercise of the freedom to choose right is limited to the accomplishment of the conditions provided in numeral four (4°) and nine (9°) of article 14 of Decree 1485 of 1994, such limitations are not required in those cases in which there is a “bad provision or suspension of the service”; thus generating these two situations as an exception to the rule.” Pages 9-10
“Dentro de ese contexto, la norma citada establece dos condicionamientos al derecho de “libre escogencia”. En primer lugar, el numeral cuarto (4°) dispone que los afiliados al Sistema General de Seguridad Social en Salud podrán hacer uso de su derecho a la “libre escogencia” una vez por año, término que se contará a partir de la fecha su de vinculación al SGSSS. En segundo lugar, en su numeral noveno (9°) impone otra limitación al derecho de “libre escogencia”, consistente en la obligación de permanecer cómo mínimo dos (2) años en una misma entidad promotora de salud, cuando esta siendo objeto de un tratamiento catalogado como de alto costo, término que empezará a contarse “después de culminado el tratamiento en la respectiva entidad promotora de salud”. Ahora bien, aún cuando el ejercicio del derecho a la “libre escogencia” se encuentra sometido al cumplimiento de las condiciones previstas en los numerales cuarto (4°) y noveno (9°) del artículo 14 del Decreto 1485 de 1994, dichos condicionamientos no resultan exigibles en aquellos casos en que exista “una mala prestación o suspensión del servicio”, configurando estas dos situaciones una excepción a la regla.” Paginas 12-13.
“That is why, outside of the legally established conditions described in numerals 4° and 9° of article 14 of Decree 1485 of 1994, barring the users of the SGSSS from transferring from one E.P.S. to another, will lead to the imposition of an illegitimate limitation which affects full access to the health social security system and endangers the rights to dignity, health and even the life of the affiliates. This behavior leads to even more grave consequences when dealing with people that require urgent, timely, permanent and quality medical attention given their serious illness, as is the case of the plaintiff, who specifically, by the refusal of Comfenalco to accept his transfer, has been forced to remain in an E.P.S. where the required medical services are not offered in a complete manner and have been interrupted or suspended without just cause.” Page 12
“Por eso, por fuera de las condiciones legalmente establecidas y descritas en los numerales 4° y 9° del artículo 14 del Decreto 1485 de 1994, impedir a los usuarios del SGSSS trasladarse de una E.P.S. a otra, conlleva la imposición una limitación ilegítima que afecta el acceso pleno al sistema de seguridad social en salud y pone en peligro los derechos a la dignidad, a la salud e incluso a la vida misma de los afiliados. Dicho proceder resulta más gravoso tratándose de personas urgidas de recibir una atención médica oportuna, permanente y de calidad dadas las graves afecciones que padecen, como es el caso del actor, quien precisamente, como consecuencia de la negativa de Comfenalco de aceptar su traslado, se ha visto obligado a permanecer en una E.P.S. donde los servicios médicos requeridos no se ofrecen de manera completa, y se han visto interrumpidos o suspendidos sin justa causa.” Paginas 15-16.
“As it has been explained, even when the Health Social Security General System guarantees its affiliate the “freedom to choose” right, it also establishes reasonable limits for its exercise, particularly, with respect to people who are subjected to high cost treatments. In this last case, the regulation on the matter pursues two fundamental objectives: (i) on one hand, to guarantee the affiliates more efficient and high quality service, (ii) and on the other, to ensure that the costs of such treatments are distributed in an equitable manner between the different entities that participate in the rendering of the health service, seeking to maintain equilibrium in the system.” Page 14.
“Como ha quedado explicado, aun cuando el Sistema General de Seguridad Social en salud garantiza a sus afilados el derecho a la “libre escogencia”, también establece límites razonables a su ejercicio, particularmente, respecto de personas que se encuentran sometidas a tratamientos de alto costo. En este último caso, la regulación sobre la materia persigue dos objetivos fundamentales: (i) de un lado, garantizar a los afiliados un servicio más eficiente y de mayor calidad, (ii) y del otro, propender porque los costos de tales tratamientos se distribuyan en forma equitativa entre las distintas entidades que participan en la prestación del servicio de salud, en aras de mantener el equilibrio del sistema.” Pagina 18.