My mother was diagnosed with breast cancer about five months back. Surgery was done at Apollo Ahmedabad and 6 cycles of chemo were done at Sterling Hostital, Baroda. Everything looks good now. As we have mediclaim policy, Surgery at Apollo was done cashless and I had to pay very little amount. After surgery doctor advised for Her2Fish report, so I had sent blocks to laboratory in Surat, Gujarat for Her2Fish report and started chemotherapy after 21 days of surgery. Her2Fish report was positive and doctor advised to start herceptin treatment after completion to 6 cycles of chemo, we are yet to start herceptin treatment.
After first chemotherapy I had sent file to medicliam company to claim amount of chemo and Her2Fish report. Here they rejected my claim and also asked me to pay back the money that was given as cashless option at Apollo. They said claim is rejected as Her2Fish report is positive. Here are the statements from madiclaim company:
"As per FISH Test reports Genetical disorder positive for Her-2 / Neu Gene Amplification / Genetic disorder detected. Hence this is not payable under clause 4.15 - Genetical disorders /stem cell implantation / surgery not payable."
"The report after sanction and payment of cashless has been positive for Genetic Disease as attached. The claim is not payable now. May I request to submit recovery of the cashless + additional payment done for this case."
So they have considered it "Genetical disorder" due to Her2Fish positive and rejected claim as "Genetical disorder" is not covered under policy .
My madiclaim policy is from National Insurance India: nationalinsuranceindia.nic....
My questions are,
1. Can it be consider as "Genetical disorder"?
2. Is anybody's claim rejected due to same reason OR Is anybody's claim accepted though Her2Fish report was positive?