19. According to the information provided by the parties, the Chilean health system consists of insurers and service providers that can be either public or private. In the case of private insurers, Isapres are entities authorized to receive mandatory health contributions (7% of wages) and are under the supervision of the Superintendency of Health.5 The petitioners alleged that the systems of regulation and control of the private health system do not ensure an adequate enjoyment of health care services but allow the rights of patients to be subordinated to the economic interests of the Isapres.6 20. For its part, the State indicated that "it has a national health system that is amply regulated, in both its public and private spheres." This system "has the Superintendency of Health, which is in charge of protecting and promoting people's rights in the area of health," and "the Health Care Funds and Insurance Authority (Fondos y Seguros Previsionales de Salud) [which] ensures that (...) [the] Isapres meet their obligations in terms of satisfying users’ rights under the law.” 7 According to the State, the health system provides wide coverage and is ranked as one of the most efficient according to international rating agencies.8 21. Based on what both parties have affirmed, the Commission notes that health insurance includes the additional option of contracting special coverage for catastrophic illnesses, which involves payment of an additional consideration. Activation of CAEC requires that the illness not be qualified by the Isapre as a chronic disease, as the relevant portion of Superintendency of Health Circular No. 7 provides: 10. IN-HOME CARE: This coverage shall proceed in relation to in-home care, upon request to the Isapre and referral by it to a provider that it designates. For this purpose, all the following conditions must be met: (...) • treatments for chronic diseases and antibiotic treatments are excluded. 22. The State said that "the granting or refusal of the agreed coverage by the Isapres may be reviewed and revoked by [the] Superintendency". The dispute settlement model is established in Article 117 of Decree No. 1 of 2005, according to which "the Superintendency, through the Health Care Funds and Insurance Authority, which acts as ‘arbitrator-judge,’ settles disputes that arise between the [Isapres] and their contributors or beneficiaries, provided that they fall within the sphere of the Superintendency’s oversight and control, and without prejudice to the possibility of the insured resorting to the instance referred to in Article 1209 or the regular courts.”10 Likewise, the State also said that a special motion for reversal (recurso especial de reposición) could be filed against the decision of the Superintendency, as could an appeal with Superintendent of Health, who decides as an “arbitrator-judge." 23. The petitioners said that Isapres "act with the utmost lack of regulation, without a regulatory framework that governs or punishes any arbitrary actions on their part." According to the petitioners, that lack of regulation creates a disproportionate burden for patients, who have to activate litigious dispute settlement mechanisms to demand compliance with their rights.11 24. In that connection, the petitioners said that “lawsuits filed against Isapres for unilaterally changing health care plans made up the biggest category of cases on the dockets of the country’s Courts of Appeal in 2010, according to the Report of the Presidential Advisory Commission on Health, December 2010."12 They also said that the insurance market is marked by conflicts of interest that affect access to services, which is the result of the so-called "vertical integration" of the system. According to a report contained in the record "(...) in Chile the Isapres that control the overall market are part of large holdings that encompass both insurers and direct providers of services related to health care, such as clinics and laboratories. By law, the exclusive 5. 6. 7. 8. 9. 10. 11. 12. State's brief of January 9, 2018. Initial petition of November 4, 2011. State's brief of January 9, 2018. State's brief of January 9, 2018. Referring to a prior mediation procedure. State's brief of January 9, 2018. Petitioners’ brief of March 6, 2017. Initial petition of November 4, 2011. 4