Sureda, Lucas v. Obra Social del Poder Judicial de la Nación

Lucas Marino Sureda, a patient who suffered from multiple sclerosis, brought this case against the Health Insurance of the Judiciary to pay for an experimental T-Cell vaccine therapy. The patient claimed that he had been under an approved treatment since 1996 and it has caused his condition to worsen. The plaintiff went to the Regina Mater Health Institute where this alternative experimental T-Cell vaccine treatment was provided. The treatment improved the patient’s health. He claimed that given his condition, he had a right to obtain a new treatment that showed positive results. The Health Insurance of the Judiciary argued that since coverage was already provided, and their obligation is to provide “basic services”, they did not need to cover additional experimental treatment. The respondent claimed that the treatment was not approved by the ANMAT [National Administration of Drugs, Foods and Medical Devices] or any other authority governing medical treatment, thus there was no scientific evidence for the efficiency of the experimental treatment.

The plaintiff based his claims on Laws 22.341, 23.660, 23.661, 24.901, 24.754 and resolutions Nº 939/2000 and 201/2002 (M.S.P.). The respondent based its claims on law 24.901.

The plaintiff brought the case to the First Instance Civil Court [Juzgado Nacional de Primera Instancia en lo Civil y Comercial Federal n° 1] which denied his claim. He appealed to the Civil Court of Appeal [Cámara Nacional de Apelaciones en lo Civil y Comercial Federal, Sala II] which conceded the appeal and ordered the respondent to cover the experimental treatment. The Health Insurance of the Judiciary filed an extraordinary appeal which was dismissed.  The respondent then filed a complaint to the Supreme Court of Justice [Corte Suprema de Justicia de la Nación Argentina] claiming the decision was arbitrary.

The Supreme Court of Justice held that the decision of the Court of Appeal was arbitrary because the Court of Appeal ignored the experimental character of the T-Cell vaccine therapy, a crucial issue in determining whether the health insurance company was compelled to cover the treatment.  The Supreme Court of Justice held that the Court of Appeal's decision was contradictory whereas health insurance must cover "basic services" according to law 24.901, but the Court of Appeal required the respondent to cover an experimental treatment.

The experimental character of the treatment is crucial to determine whether health insurance companies must provide it. Because the Court of Appeal did not ask the parties to provide evidence of the experimental character of the treatment, the Supreme Court ordered that the case be returned to the Court of Appeal to request new evidence from the parties and rehear the case.

"[...]El carácter experimental del procedimiento está matizado, en este contexto especial, por dos elementos esgrimidos oportunamente (la respetabilidad científica y el ajuste a las pautas de la autoridad de aplicación sanitaria) que resultaban, a mi entender, vastamente idóneos como para requerir un análisis que se obvió por completo" Paragraph IV

"[...] The experimental character of the procedure is nuanced by two elements (the scientific respectability and the adaptation to the health authority's guidelines) that resulted vastly ideal to require an analysis that was completely ignored." Paragraph IV

"Los jueces de la causa, deberían haber requerido con carácter urgente -previo a resolver en definitiva la cuestión-, una exhaustiva evaluación médica especializada, que ilustrase, cuando menos, sobre los siguientes puntos: 1) la evolución operada en el proceso patológico que afecta al actor, su estado de salud actual y su pronóstico; 2) la descripción del procedimiento propuesto; 3) las consecuencias que éste puede acarrear, complicaciones frecuentes, riesgos razonablemente previsibles, y efectividad; 4) la existencia de terapias alternativas; 5) los beneficios y desventajas de la nueva práctica, así como los que correspondan a los tratamientos convencionales; 6) la necesidad o no de la administración de la estrategia médica en cuestión; 7) en caso afirmativo, los recaudos que deben adoptarse sine qua non ; 8) la apreciación técnica integral referida al caso concreto, con las indicaciones terapéuticas que se juzguen mas adecuadas." Paragraph VIII

"The judges should have urgently requested, before solving the lawsuit, an exhaustive medical evaluation that illustrates the following issues: 1) the evolution of the illness that affects the plaintiff, his health condition, and his prognosis; 2) the description of the proposed procedure; 3) the consequences of it, usual complications, and reasonably predictable risks and effectiveness; 4) the existence of alternative therapies; 5) the advantages and disadvantages of this new practice, as the ones corresponding to conventional treatments; 6) the need for the medical administration; 7) if this is the case, the necessary measures that should be adopted; 8) the comprehensive technical assessment with the therapeutic indications that are considered more appropriated." Paragraph VIII