Transtuzumab(monoclonal antibody) and insurance

[Pinkribbon]

Is Transtizumab used in cancer treatment in Govt Cancer hospitals?

What is the exact terms and conditions in the Insurance policy that refuses reimbursement for monoclonal antibody treatment for cancer?

[sumeet_shah Administrator]

I am sure wherever a qualified Medical Oncologist is working at a Government setup, Trastuzumab must be given.

Insurance cannot refuse Trastuzumab. All Insurance companies sanction the same. I have barely come across anyone where Trastuzumab was rejected. If there is an issue with your insurance, you can take help of your Medical Oncologist who can write that it is a targeted treatment and is sanctioned by all other Insurance companies.

[Pinkribbon in reply to sumeet_shah]

That's nice to hear. Can u name any insurance companies who approve vivitra.

In fact vivitra along with chemo was approved by the insurance..they are creating problem only for stand alone dose of vivitra.

[sumeet_shah Administrator in reply to Pinkribbon]

Don’t know specifically. I am a Surgical Oncologist and don’t give chemo. So honestly, not aware finer details as to which company approves. But I believe all should approve. There is no reason for any insurance company to reject it. Once more I repeat, the person who can help you here is your own Oncologist who has prescribed Vivitra.

[prasad_231 in reply to sumeet_shah]

I too faced this issue. National insurance has rejected all claims for trastuzumab stating it is 'adjuvent' and not life saving category. Ita ridiculous that insurance company started rejecting half way through. Any help on this matter will be welcome as the cost burden is humongous to bear.

[roxboxfox RadiationOncologist in reply to prasad_231]

Your Oncologist should be able to sort this out for you.

[prasad_231 in reply to roxboxfox]

Hi, I did check and he provided a letter stating the importance of the medication so that I can forward to the insurance company.. But the doctor also mentioned that many similar cases were facing challenge from insurance companies and no amount of push was working as there seems to be some mis-understanding at the IRDA level..

[Pinkribbon in reply to prasad_231]

There are 2 ways to handle this as I see

1. Either we approach Ombudman

2. Consumer court

In either way we should prove that it's an establised treatment course and we should use all 17 cycles to finish the treatment.

That's y I have asked if the treatment regime is same in Govt hospitals also

[prasad_231 in reply to Pinkribbon]

roxboxfox Pinkribbon sumeet_shah

Helloeveryone, I checked with our oncologist also. He also mentioned that insurance companies have started rejecting and they have also tried lobbying. But as of now we will be forced to bear the cost ourselves.

[D1002]

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 [e-mail].

[roxboxfox RadiationOncologist in reply to D1002]

What was the update / outcome of the claim for your Herceptin treatment

[prasad_231 in reply to D1002]

Hello, any update on the filings

[sananc04 in reply to D1002]

Sir,

My herceptin claim is taken under juduciary of kolkata ombudsman and the case will be on hearing very soon. So i want to prepare myself on justifying my claim to honourable judge. Since u have researched and done compilation can u guide me by sharing some valuable point which i can put forward in support of my claim. For information i would like to share that the standalone herceptin is rejected by New India Assurance company by raising the clause that this type of procedure does not require daycare admission and can be taken in OPD basis.. my mail id [e-mail]. Best Regards Santanu Chatterjee

[ghataksumita]

Guideline of Indian Council of Medical Research for treatment of breast cancer page 28 may be seen.