TRASTUZUMAB TREATMENT REJECTING BY UNI... - Breast Cancer India

Breast Cancer India

3,100 members1,447 posts

TRASTUZUMAB TREATMENT REJECTING BY UNITED INSURANCE WHICH IS MUST HER2 POSITIVE

KVLV profile image

GHPL (UNITED INSURANCE) IS REJECTING TRASTUZUMAB SHE REQUIRE INJ HOW CAN I GET INSURGENCE WHAT IS THE PROCEDURE EXPENSIVE TREATMENT WE CAN NOT STOP, ANY LEGAL PROCEDURE IS THERE

23 Replies
kontak profile image
kontakTeamBCI

Yes I think you should get the claim. Try to get letter from insurance why they have rejected. Take the same letter to your oncologist - we will give a technical reply to you which you can again submit to insurance. This will help

KVLV profile image
KVLV in reply to kontak

Subject :Denial Of cashless facility for Hospitalization of K NANDA

GOOD HEALTH ID: GHUIAB00265395

Dear Sir/Madam,

This is in reference to your request mentioned above for cashless hospitalization of the above patient. On

primary scrutiny of the submitted documents and verification of the insured persons'insurance policy

terms, we advise that we will not be able to issue the authorization for cashless hospitalization. The

doctors'note explaining the reason for this denial follows:

Doctors Note :

• CASHLESS FACILITY CANNOT BE EXTENDED AS PER POLICY TERMS AND

CONDITIONS HOSPITALIZATION ONLY FOR MONOCLONAL ANTIBODIES INJECTION

NOT PAYABLE HENCE DENIED

Authorized Signatory

IMPORTANT: GHPL KIMS HOSPITALDENIAL OF CASHLESS FACILITY

To, Date : 12-AUG-2017

KRISHNA INSTITUTE OF MEDICAL SCIENCES

Door No.1-8-31/1, Opposite Sai Baba Temple,,

Main Road,Krishna Colony, Minister Road,

Hyderabad West - 500003

HYDERABAD

CC No. : 183707

KVLV profile image
KVLV in reply to KVLV

WHEN I CONTACTED GHPL THEY ARE NOT ASSURING FOR REIMBURSEMENT THEY SAID IT WILL BE DISCRETION OF UNITED INSURANCE WHAT I CAN DO SHE WAS SUPPOSED TO TAKE ON 11 TH AUGUST

You can go to insuranc site and check the day care procedures.. Most of insurance included chemo in datcare. If chemo is in day care then they must need to reimburse.. It does not matter which drug u r using.

Reach to grivience cell of insurance company first. If not happy with their response you can escalate to IRDA. Give ur complaints in writing with supporting documents n take acknowledgement from insurance cmpny. They should deal within 15 days n then u can escalate i t to irda.

Irda toll free 155255 or 18004254732 or send mail to complaints@irda.gov.in.

Search another post on health where u can get more help.

unlocked site with title heclon not paid by insurance company

Wishing ur family member happy recovery.

AjayKK profile image
AjayKK in reply to Ashish31

This toll free number is not working.

Please refer : healthunlocked.com/breastca....

Hi,

Please refer to the related posts in this forum. Quite a few of us have had this issue of Herceptin coverage in the medical insurance. Please take it up with the TPA representative with Oncologist letter - treatment plan . In our case , cashless facility for the Herceptin day care was repeatedly rejected, but we could get the reimbursement in 4-6 weeks after submitting the daycare claim after each of the sessions.

Thanks,Senthil

United India paid for my Trastuzumab but not on cashless basis as i did not have that kind of policy. If you submit your claim and they reject it, you must write to the Grievance Cell of the company. If they reject it too (as they usually do), then go to the insurance Ombudsman... i think there is one in every major city. Look it up online and you will get the whole procedure. I have twice appealed to the Ombudsman for other issues and have won my case. Insurance companies bank on the fact that consumers will not be bothered to appeal.

KVLV profile image
KVLV in reply to Sherna

can i get mail id of ombudsman

Sherna profile image
Sherna in reply to KVLV

In Mumbai the postal address of the ombudsman office is:

Office of the Insurance Ombudsman, Mumbai, Jeevan Seva Annex, 3rd Floor, S.V. Road, Santacruz (West), Mumbai - 400 054.

thanks

Thank you

HI All

I am getting below reply from oriental insurance policy. I am trying my level best to clear my dues but getting negative reply.

Reply From Oriental insurance:

Hi Mr. Kisankasare,

Pl find below appended our Doctor's Opinion about the admissibility of the claim. Our panel Doctor says that the stand alone injection is not payable but the same can be paid if the injection is administered along with conventional treatment or as post hospitalisation claim. So we are also of the opinion that the claim is not payable as per our policy terms and conditions.

"

Dear All

The insured is an old case Ca breast with metastasis on treatment now on Heercolon injection given IV . This is an monoclonal antibody acts on tumor cell differently . This drug is not considered as an malignancy chemotherapy. In general all the insurer are not covering stand alone , and covered when taken along with anti malignancy chemotherapy/ as pre and post claims

This is basically an OPD procedure and hospital admit as this particular drug so expensive "

Hi,

I am facing the same problem for my mothers trastuzumab treatment cycles. Request your help and support

Pinkribbon profile image
Pinkribbon in reply to ango

Hi, We are facing the same problem for Transtuzumab treatment for my mother. we have finished chemo and recently came to know about this rejection of monoclonal antibody treatment by insurance companies. My TPA is GHPL. Hope you have read earlier posts. Approaching Ombudsman is one way. Am not sure where his office is in Hyderabad. Second is to approach Consumer Forum.

Cancer treatment has gone to a new level , thanks to these drugs. we get into the dilemma to be happy for new drug or how to face the burden of the drug as they are very expensive. But Vivitra is part of the universal protocol for cancer treatment for Her2 + cases. Insurance companies should not object them.

My mother was given Carbo and Paclitaxel. both of them put together costs not more than 4500. While Vivitra is 60000 and Perjeta is 250000. these are life saving drugs. Only for 5000 treatment we don't need insurance. Infact insurance itself is to lend us a helping hand for these new treatments. But it looks like otherway round

ango profile image
ango in reply to Pinkribbon

Thank you pinkribbon for the reply. As pointed out, yes i have referred to the earlier post but i noticed one common thing- very few people have confirmed that they have managed to receive their claims after escalating to Ombudsman and/or Consumer forum (except for one or two places where they had corporate mediclaim). As adviced by you, we will be escalating to both Ombudsman and Consumer Forum.

My insurance is Oriental Family floater and TPA is Health Insurance TPA of India LTd. (HITPA). My mother completed her normal chemo cycles along with trastuzumab (whgich were approved ) but now only stand alone 10 trastuzumab cycles (Vivitra) are pending which are getting rejected. I wanted a reference case in Oriental Insurance or any other insurance so that we can fight the case more confidently. Secondly I wanted some documentary evidence to support our case, eg i found 2 cases online (not similar to my mothers scenario) settled by ombudsman related to trastuzumab treatments, but could not find any source where there is an approval or denial to use this medicine. So mainly wanted help as to how to fight this case when approaching to consumer forum and Ombudsman.

If it is giving along with chemo treatment they are approving only Transzumab is rejecting

ango profile image
ango in reply to KVLV

Same here. They are rejecting stand alone Vivitra (trastuzumab) treatment cycles

I am Deval Patel, a solicitor who has suffered the same misery at the hands of United India, my insurance company.

I have taken up this issue both with the Insurance Ombudsman and the IRDA.

Last week I have submitted a 200 page compilation, including opinions of Medical Oncologists, Articles on the criticality of Trastuzumab and Technical papers on the subject. I am waiting for their responses.

In the meantime, if you would like to receive updates on my crusade for the inclusion of Trastuzumab in insurance claims, please contact me by email with your case details on Deval1002@gmail.com.

PrityJ profile image
PrityJ in reply to D1002

Regarding your crusade against insurance companies for rejecting Trastuzumab (Herceptin). I am a Breast Cancer warrior and currently under treatment. I am also facing the same issue of rejection by Mediassist.

Kindly let me know about IRDA and insurance ombudsman development. Really appreciate your fight against the insurance companies. I have sent u an email also.

I am Rajan Pakhare. My wife is detected with breast cancer in right breast. Insurance company has rejected the standalone Trastuzumab treatment. I approach to DivineVision NGO group. This group is supporting me in getting the claim. Now I have prepared the case and going to submit to ombudsman. I am thankful to this group.

Madsd profile image
Madsd in reply to Pakhare

Hi Pakhare.,

Were u able to get the claim after going yo obudsman. Can u please send me the case outcome to my mail id - madhu7bitmesra@gmail.com

You may also like...