BC PT2N3MO, with HER2+ ER+ PR+ undergoing Trastuzumab

BC PT2N3MO, with HER2+ ER+ PR+ undergoing Trastuzumab

Hi,

My Mother was diagnosed with Breast Cancer PT2N3MO, with HER2+ ER+ PR+ last year in September.

Undergone with modified radical mastectomy, followed by Chemotherapy (ECF * 3 & T*3) then Radiation therapy.

All were covered under Insurance (Surgery, Chemo, Radiation) Except Trastuzumab.

We were suggested to consider Trastuzumab (18cycles * 21days), which we started after radiation.

Currently 4cycles Trastuzumab(Hertraz) completed.

As initially planned, we thought Insurance would cover major chunk of medical expense.

But as shock it got rejected considering it as Hormonal therapy. After providing a letter from our doctor of nature of medicine as Monoclonal antibody later it got rejected as under a clause.

“Procedures/treatments usually done in Out Patient Department (OPD) are not payable under the policy even if converted to Day Care Surgery Procedure or as inpatient in hospital for more than 24 hours.”

Does Trastuzumab really considered under OPD/Is there any turnaround for this kind of scenarios.

It’s Very disappointing that even for this kind of malignant disease these reasons would apply.

At this point am really worried as with whom we need to fight!!! Is it with Disease? Or roam around this Insurance providers.

Still we are due with 14 cycles and am really worried on future course of action.

Thanks

4 Replies

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  • Trastuzumab is very much covered under insurance. Rulesvary from company to company. You may probably want to get in touch with a few patients under the same Oncologist who are also undergoing Herceptin treatment and whose insurance has been covered and see.

    You must fight for it. Herceptin is definitely covered. Your Oncologist will be the best person to guide you.

  • My insurance company is paying for the trastuzumab. Insurance companies always try to wriggle out of making payments. Write to the Grievance Cell of the company and if they don't help then there is a process whereby you can take your case before the insurance ombudsman. I won my case there in another matter. The thing to do is to challenge the company if you have a strong case, which very few people bother to do and so the insurancewallahs get away with it.

  • Thank you Sherna,

    I have addressed my issue with insurance company greviance cell but as stated earlier, those were their reply.

    But am planning to approach Ombudsman to get things further.

    Could you please let me know if 24hours hospitalization is mandatory for trastuzumab for claiming insurance.

    Thanks

  • No it is not. I just go to the hospital for the two hours or so that it takes to be given the meds. If you are located in Mumbai the ombudsman here is very good. Ask for a personal hearing.

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