Argentina’s Federal Civil and Commercial Court of Appeals has ordered Swiss Medical to fully cover gambling addiction treatment for a 20-year-old patient at a specialized rehabilitation center outside its provider network, where he has been receiving care since 2023.
The ruling upheld a lower court decision requiring the insurer to provide comprehensive coverage for all therapeutic services and prescribed medication at the patient’s current treatment facility. Judges found that continuity of care was medically justified and that contractual limitations imposed by the insurer could not override clinical recommendations.
The case originated from an injunction filed by the patient, identified in court documents as E.N.M., who was diagnosed with gambling addiction accompanied by depressive symptoms. Medical records submitted to the court indicated that the patient had shown favorable progress and strong adherence to the intensive treatment program recommended by his treating team.
Swiss Medical appealed the initial ruling, arguing that it had not refused coverage but had questioned the choice of treatment center, as it was not part of its contracted provider network. The company maintained that it had offered alternative institutions included in its medical plan and that its contractual obligations were limited to in-network providers.
The appellate court rejected those arguments, noting that the insurer failed to submit technical or medical evidence challenging the treating physicians’ recommendations or questioning the qualifications of the professionals overseeing the patient’s care. Judges also observed that the appeal largely reiterated previously stated positions and referred to medical conditions unrelated to the specific case.
In its decision, the court framed the case under Argentina’s Mental Health Law No. 26,657, which classifies addictions as part of mental health policy, and Law No. 26,934, which established the Comprehensive Plan for Addressing Problematic Consumption.
Under this legal framework, private health insurers are required to provide free and comprehensive coverage for treatments related to problematic consumption included in the Mandatory Medical Program.
The judges concluded that the patient requires intensive and comprehensive treatment and that his continued care at the same facility was essential, given his level of adaptation and adherence since 2023.
They further noted that Swiss Medical failed to demonstrate that it had an equivalent in-network provider capable of offering a comparable therapeutic approach or to explain the potential consequences of interrupting an ongoing treatment process.
In a related case in Brazil, a state court ordered two online betting platforms to permanently exclude a compulsive gambler from their services, recognizing gambling disorder as a psychiatric condition requiring judicial intervention.
Buenos Aires Province and Buenos Aires City have expanded public programs for gambling addiction in recent years, including outpatient treatment and dedicated helplines, particularly targeting young and online gamblers
