Cashless insurance rejected for HER2 breast cancer, reason cited as an "unspecified lump in the breast(by NIVA BUPA)

[Veenakc]

my wife, 40 year-old, who recently received a diagnosis of breast cancer (HER2 positive). On September 22, 2024, she experienced breast pain and discovered a lump in her breast. She consulted a clinic in Bangalore, where they advised her to see a breast surgeon. Subsequently, she visited a specialist at Sri Shankara Cancer Hospital, Bangalore, and after a week of diagnosis, it was confirmed that she has breast cancer (HER2 positive).

We are eager to initiate the necessary treatment and have a Niva Bupa Family Floater Insurance policy effective date: 27/09/2023) , which, according to the policy documents, covers cancer treatment after a waiting period of 30 days. However, when we applied for cashless service, the request was rejected with the reason cited as an "unspecified lump in the breast."

The medical records from the hospital clearly state that it is breast cancer with HER2 positive. I am perplexed as to how the diagnosis could be misinterpreted, leading to the denial of the claim. This raises serious questions about the ethical practices of either the hospital or the insurance company. As patients, we are left confused and deeply concerned about whether this issue stems from a misdiagnosis or a flawed assessment by the insurance company.

I written IRDAI to urgently look into this matter, as my wife's breast cancer is in its early stage (not beyond lymph node) and requires immediate treatment. Moreover, the insurance policy is in effect, and the diagnosis was conducted at a reputed cancer hospital. The PET-CT scan and histopathology reports clearly indicate breast malignancy, yet Niva Bupa is denying the claim, refusing to acknowledge it as cancer. Both the hospital and the insurance company have left us in a state of distress and uncertainty. We are in great trouble, unsure of who is right. I want to know from this platform anybody experiance similar situations? Please let us know how to deal this situations. How to battle this? IRDAI rally help this matter or it is just like another govt agencies and have understanding between insurance company shut eyes?.

[sumeet_shah Administrator]

You are definitely entitled to your insurance, as the lump was discovered way after the waiting period. I am unable to understand what does the insurance company mean when they write ‘unspecified lump’. When the biopsy report clearly mentions this as breast cancer, there is no ambiguity. Please talk to your Insurance agent and also write an email to the company (I am sure you have already done that); just resend the biopsy report and you can ask them what exactly is the reason they have refused. Also, you can ask the Hospital TPA team what is the issue? They might be able to shed light further. Let us know here; if there is some suggestion, we shall surely let you know.

[Veenakc in reply to sumeet_shah]

Thanks. yes we have written yesterday(12th Oct 24) to insurance company and rise the complaint with IRDAI . We are worried Insurance company just denied citing single word "unspecified" lump. hospital people are telling our report are right, it is breast cancer with HER2 positive (score 3). Here Insurance company assessment problem or ethics.

IHC report

[sumeet_shah Administrator in reply to Veenakc]

This is the IHC report (Immuno Histo Chemistry), not the biopsy report. There will be one more report of biopsy where it will be mentioned that this is cancer - Infiltrating Breast Carcinoma or Duct Carcinoma or Lobular Carcinoma. Or it may be on the previous page of this report. Please check. That is the report which you will need to submit.

[Veenakc in reply to sumeet_shah]

FNAC report

FNAC report

[Veenakc in reply to sumeet_shah]

PTCT report

PTCT Report

[Veenakc in reply to sumeet_shah]

PTCT

PTCT interpretation

[Veenakc in reply to sumeet_shah]

We got approval for cashless treatment after doctors letter. Thanks you.

[Veenakc]

Thanks for going through report here the report

Histopathology repot of biopsy

[sumeet_shah Administrator]

This last report mentions the words ‘suspicious for invasion’, implying they are strongly suspecting cancer; and pre cancer is there for sure. The first report of FNAC from lymph node shows metastatic carcinoma. Both these reports, considered together, are unequivocal proof of cancer and your insurance company should definitely admit the claim.

[sumeet_shah Administrator]

maybe a letter from your treating doctor, will help.

[Veenakc in reply to sumeet_shah]

Thanks a lot for kind reply we will meet the doctor and ask for the same.

[Veenakc in reply to Veenakc]

Sir, can you share email Id we will mail the report treatment plan

[Sidduram]

Dear Veenakc,Sorry to hear about your wife's diagnosis, My wife also had ER /PR negetive and HER2 positive stage 4, She was given Herceptin along with chemo totally 6 doses,, my insurance New india insurance settled my claim for the full amount, initially they were reluctant saying herceptin is a hormone drug, A strong letter from our oncolgist proving that it is not a hormone drug and has been used along with chemo and not separately, this convinced them,

maybe in your case there is no oncolgist in the panel of Doctors who scrutinized the insurance papers, keep trying is the only hope,

[Veenakc in reply to Sidduram]

Sidduram Thanks for the reply.

[Veenakc in reply to Sidduram]

got approval and 1st chemo started.

[Sidduram in reply to Veenakc]

Great, hope all isvwell❓

[sroshan20]

Hello Veenakc and Sidduram , my wife (aged 39) also diagnosed with Breast Cancer Her2+ve stage 4 on last week of Oct.2024.

We showed her in Oncology hospital in Bangalore.

Since it is Her2 +ve hence doctor recommended Cheemo + Target Therapy.

Did you guys try any Ayurveda Or any other type of treatment apart from the one prescribed by your Oncologist ?

Thanks !

[Sidduram in reply to sroshan20]

Hi Roshan,Don't think twice, go with your oncologist treatment, There is no solid proof that Ayurveda cures cancer, At one stage without you knowing it becomes food for cancer, I have seen my sister in law shift from Allopathy to Ayurveda and losing the race and her life, For Her 2 positive you have a wonder drug Herceptin, ask your oncologist, wishing your wife a speedy recovery

[Srikalakm in reply to Sidduram]

Never trust ayurvedic here

Doctor would have suggested phesgo (pertuzumab + transtuzumab )+ paclitaxel or docetaxel . Even though cure is tough it’s far better than ayurvedic.