Can mediclaim get rejected due to Her2Fish positive?

Hi All,

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?

22 Replies

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  • Hi motiap - First of all see & study your policy in a very detailed manner. See if there is any clause of genetical disorder or anything like it. Then we can see if we get any technical help from anybody

  • Hi Kontak,

    Thanks for quick reply. This is the clause in policy : clause 4.15 - Genetical disorders /stem cell implantation / surgery not payable

    so I want to confirm whether my case is "genetical disorder" or not.

  • HER 2 positive is not genetic disorder/disease. Does the FISH report specifically state it is a genetic disorder/disease. I am also HER 2 positive and all my claims have been settled. Get a letter from your oncologist that it is not a genetic disorder/disease and submit to insurance company. Public sector insurance companies are funny

  • Hi Greenbear,

    Thanks for reply.

    There no statement in FISH report regarding genetic disorder. I have already submitted letter from oncologist however insurance company is not ready to change their decision. I am thinking of going by legal actions so just want to confirm things here before I proceed for the same. Again thanks for your quick reply.

  • pl go to higher up in insurance company and insurance ombudsman before going to court. The insurance company will have an escalation heirarchy. Usually some ignorant medical practitioners are sitting in the claims department. I think you will succeed if you go higher up.

  • Moitap - as informed by green bear go to higher authorities of the insurance agency

  • Motiap, greenbear said correctly her2 positive is not genetics disorder but u know these insurance companies tries to find out the way to escape from claim...so if u discuss higher authorities, your case will be settled...our wishes are with u.

  • Thanks motip greenbear for raising this issue. This is really a matter of concern for all .

  • Hi motiap,

    I have the following to say:

    1. This is ABSOLUTELY not a genetic disorder. This is a test for mutation in genes and is NOT a congenital genetic disorder

    2. None of my patients (many of them from New India Assurance) have experienced this. All of the claims were passed.

    Incidentally, two days back, for one of my young thyroid cancer patient, 15 years old, for whom I had done a BRAF mutation test, got a letter that her claim was rejected because of genetic test and blah blah blah, according to clause 4.4.16 (Genetic Disorders etc.). I wrote a letter yesterday and gave it to her father to submit it for the claim. And I am going to fight for her and ensure she gets the money which rightly belongs to her. Here is a copy of the letter for you to read:

    l32i.imgup.net/hu3f6c.gif

    The problem with these Mediclaim chaps is, they do not know the difference between 'congenital genetic disorders' and 'genetic tests'. They club both of them, though they are not similar. And there is so much corruption in these medi claim companies and their TPA's. TPA's are paid an amount by their Mediclaim companies to reject as many claims as possible. They reject even routine claims for no obvious reason and cause extreme levels of inconvenience to the applicant who has to run here and there, waste time and energy, running for the money they rightly deserve to be re imbursed. People who do not know a word on medicine and its implications, judge whether you can get your claim or not!! And to mention here, though not related, more than 90% of authorities in Health ministry of India and almost all who are invloved in planning and implementation of Medical Education in India are non medicos (and are pure politicians), who do not know what it takes to become a doctor. It is these non medico ministers and MLA's who decide the fate of doctors and medical education!! This is India.

    You MUST fight for this, motiap. Ask your doc to write a letter to your mediclaim company. Thousands of women undergo HER2 testing daily. And all mediclaim companies re imburse cost for Herceptin as well, as long as the amount of mediclaim covers it.

  • Thank you Dr. Shah for a good detailed explanation. I am going to contact higher authorities tomorrow, lets see how it goes. I will keep updating here my course of actions. Thanks again for quick and detailed reply.

  • Dear Dr. Shah,

    I, as a BC patient, am facing the same problem with the insurance. In my case insurance was approved twice post surgery. Now they are rejecting. This is my 17th cycle. Please find below the response given by a consultant of the insurance who is also a doctor:

    "I have perused the trail mail and also Doctor note. Patient is case of Ca Breast treated with anti malignancy chemotherapy and Transtuzumab.

    Now planned for Transtuzmab alone, this drug in monoclonal antibody not cosidred as chemoto therapy drug and hence claim is not payable and also the same can adminstred as OPD procedure".

    Kindly give your advice.

    Thank you

    Getzi

  • Hello Getzi,

    Same thing happen for my mother claim also.

    Your claim is considered or not?

    Thanks,

    Gaurav Kurvey

  • If higher up authorities in insurance company fail to give positive response then there is an insurance ombudsman who is a representative of IRDA that is the insurance regulatory authority.Contact details should be available in your policy. Sad that you have to waste your time in all this when you should be concentrating on the treatment. You will need insurance as Herceptin is very costly.

  • Her2 Positive breast cancer is certainly not a genetic disorder but an acquired mutation driver in the 17 p chromosome. All what the test seeks to answer is that once the breast cancer has occured, is there an accelerated driver to this cancer or not.

    It is pitiful, how ignorant are the mediclaim officers out there who probably have no clue to what this means. You should try and get this published in Times of India and of course appeal and go to higher authorities. You will now undergo treatment with HERCEPTIN, and there is a huge cost to this, and if they are going to cover HERCEPTIN costs, on what basis would they not cover the mere test which proves you are Her 2.

    Please preserve all these documents and write and insist on written letters and information, and not verbal excuses from these babus.

  • Very aptly said, roxboxfox. Thanks.

  • Apparently from what motiap has written Dr. Rohit they are not going to pay for Herceptin as they have asked to refund the cashless claim recd for surgery and chemotherapy. It is just ignorance on the part of the mediclaim doctor. I am sure higher authorities would pass the claim. I think all cancers are a result of gene mutation. If this is not covered then no cancer patient would get a claim settled. Genetic disorders mentioned in mediclaim policies refer to congenital disorders either inherited or acquired. It is just irksome at a time like this to deal with all this.

  • I had logged grievance complain a week ago. Today I got reply stating they will do payment. Here is their reply:

    "The matter has been discussed in view of grievance raised for the case during our visit to MD INDIA TPA office, BARODA , on 21.01.2015, the treating doctor has clarified that this can not be taken as Genetic Disease as this is a case of Breast Cancer. Therefore MD INDIA TPA is considering the case for the payment in favour of the insured. "

    Thank you all for your support and help.

  • Hi,

    I had raise one claim for my mother for Herceptin. But insurance company deny the insurance and give the below comment:

    "As per the confirmation from our concerned team, we regret to inform you that chemotheraphy with herceptin injection is not covered under the policy."

    Herceptin is under Hormone replacement therapy??

    Please suggest me what can I do now.

    Thanks in advance!!

  • Great relief that you dont have to spend too much time battling to get this.

    Thanks for the feedback as well.

    (Glad to see quick and right justice done).

    You can now concentrate and get back to the unfinished goal of finishing your mothers treatment with Herceptin.

    All the best to your mom !

  • This is good news

  • If Fish report is positive means its a genetical Disorder

  • Hi Sundari, please read the full post, as the medical professional if FISH test is positive it doesn't mean its a genetic disorder...FISH test is know about gen mutation..

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