Herclon under mediclaim

My wife has grade 4 HER positive metastatic breast cancer.

The doctor has tried various medicines/ combinations and now she is on Herclon + Tykerb. I have a group mediclaim policy of Oriental Insurance through my office. The insurance company has declined claim on following grounds:

1. Infusion of Herclon is not Chemotherapy.

2 Patient is HER positive so it is genetic disorder which is excluded from cover.

3. Herclon is an advanced treatment. Medicine is expensive. So not covered. As per doctor no other less costly medicine is working now.

I would contest if my claim is just and fair. If the reply of TPA of insurance company is correct then I will have no option but to give up.

Please suggest reply to insurance company.

4 Replies

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  • Since I do not give chemotherapy, I would not be the right person to guide. But I feel, you must ask your Medical Oncologist to reply to all those three questions and your claim will pass.

    1. Infusion of Herclon is definitely a part of chemotherapy called Targeted therapy and all insurance companies reimburse it.

    2. HER2 positive is not a 'congenital' genetic disorder. HER2 is assessment of which genes the tumour expresses and 'targeting' those genes accordingly.

    3. It is not 'advanced' treatment. It is 'standard' treatment.

    If you Oncologist writes this on his letterhead, you should be easily able to get through. No insurance can refuse this. Fight for it.

  • Dear Mr Shah,

    I am grateful to you for quick and pointed reply. This show how TPA of insurance company is harassing people. The patient and their relatives aren't expected to know such technicalities. The patient and relatives are fighting with cancer but these TPAs are forcing them to fight with TPA also. But I now get energy to fight.

    Sir, in the meantime, can you give reference of some court decisions on these issues. Regards.

  • Please follow this post

    We ve had few members who faced this problem and overcame this very easily.

    healthunlocked.com/breastca...

    Connect to these ppl to boost your confidence.

    Seek help from your Medical Oncologist (who probably has not being treating his first Patient with Herceptin who has Medical Insurance) but perhaps is busy.

    Escalate to Grievance Team /Complaint to get this cleared.

  • I too had this problem but don't give up as my claims were processed after 3-4months of time.. Its just that these agents get some % of money when they reject claims and save for the company.

    Refer to these links:

    healthunlocked.com/breastca...

    healthunlocked.com/breastca...

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