Right to health and a decent and dignified life. Breast reconstruction procedure included in the healthcare plan

Y.R.M.G. (Jane Doe) v. Coomeva E.P.S.

Date:  09/30/2019

Judge-Rapporteur:  Carlos Libardo Bernal Pulido

Facts.  The plaintiff was diagnosed with obesity and bariatric surgery was performed as a treatment for this condition. This surgical intervention produced a massive loss of weight and with it, generalized adipose-cutaneous flaccidity, breast atrophy, and lipodystrophy. In turn, moisture is produced in the folds of the skin and this causes itching and dermatitis. Coomeva E.P.S., the health care company, refused to authorize the practice of the bilateral breast reconstruction procedure with prosthesis and composite flap, ordered by the treating physician.  The defendant institution argued that said surgery’s main purpose is of a cosmetic or luxury purpose.

Issue: Is breast reconstruction procedure always aimed at a cosmetic purpose, or it may imply a health need, and therefore be included in the health care plan?

Ruling and reasoning.  Yes, it may be determined by health considerations.  The Court, in contrast to the company, averred that a reconstructive plastic surgery with functional purposes, is necessary for the maintenance of the functional, psychosocial, and sexual development of the patient and, therefore, is not excluded from the health coverage plan.

As a consequence, the Court GRANTED the protection, and ordered the health care company to approve the practice of the surgical procedure required by the petitioner, as well as to provide her with pharmaceutical and therapeutic treatment led to her definitive recovering.