Herceptin not covered by insurance

My mom has been diagnosed with Her2+ breast cancer. She has undergone 6 rounds of chemo+herceptin completely covered by insurance. Now for the remaining 11 rounds of only herceptin my insurance company (United India Insurance Company) is refusing to cover it. The documentation clearly says chemotherapy is covered and UIIC claim that herceptin is hormone therapy. Has anyone else faced this issue and did you overcome it?

3 Replies

  • Herceptin is definitely covered by Insurance. It is not a hormonal therapy at all, it is a targeted therapy and all insurance companies will pay for it.

    The problem is, the system. A person of a level of clerk or an basic doctor, who does not even know medicine fully, is usually hired by these insurance companies to look into claims and they are always encouraged (by various means) to refute as many claims as possible. It's very painful and I too very much see it regularly, on and off, with my patients. If your mediclaim amount is sufficient enough, they should definitely sanction for Herceptin. You must talk to your agent and if need be, request your treating Oncologist to help here. Till date, in my patients, where such claims have been refused for dubious reasons, I have always given a very kind and explaining letter (without any harsh words), and to my knowledge, almost all of them have got their claims settled. Your doctor will help you out here.

  • Same happened to me under Mediclaim. They refused to pay for herceptin. Took a lot of calls, letters from Doctors, email exchanges etc and a lot of time and tension to prove the insurance company that herecptin is targeted therapy and is needed for my treatment! . But luckily as the insurance was from my office there was a dedicated agent who got the corporate insurance. So he was my punch bag everytime insurance was rejected. But at last got it after 2-3months wait. So do try and do not give up on these insurance companies. or else write to IRDA in case they still don't approve

  • I faced same issue with medimanage.They refused to pay for Herceptin . They paid only if it was given with chemo.As prabu said please do follow-up with doctor letters.

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