When corporate lawyer Deval Patel signed up for a mammogram after her 46th birthday in 2016, little did she know she would be diagnosed with an aggressive grade three HER2 positive breast cancer. Despite three surgeries, 30 chemotherapy, HER 2 therapy and radiotherapy sessions, she got her insurance company to reimburse 50 per cent of a life-saving medication, Trastuzumab, sold under the brand name Herceptin.
“That’s when I realised that along with early screening, access to drugs and knowledge of insurance was most important,” says Deval, who now runs a cancer care fund herself to help underprivileged patients avail these injections.
HER2-positive breast cancer accounts for 20-25 per cent of all breast cancers, says Dr C B Koppiker, oncoplastic breast surgeon and founder of Prashanti Cancer Care Mission. Some of HER2 positive patients also have ER (estrogen receptor) and PR (progesterone receptor) positivity. If a cancer cell is ER+, it means it can receive signals from estrogen, instructing the cells to grow. If a cancer cell is PR+, these signals can come from the progesterone hormone. This triple positivity opens up several options for effective targetted therapies and cure. “Patients with HER2-positive breast cancer respond well to targetted drugs like Trastuzumab and even more effective newer options,” he adds.
Despite three surgeries, 30 chemotherapy, HER 2 therapy and radiotherapy sessions, she got her insurance company to reimburse 50 per cent of a life-saving medication, Trastuzumab. (Express Photo)
The battle with insurance
Trastuzumab (sold under the brand name Herceptin among others), a monoclonal antibody, is the gold standard for HER2 receptor positive patients. It blocks the ability of the cancer cells to receive chemical signals that tell them to grow and is administered as a drip or a subcutaneous injection. However, the insurance company dismissed Deval’s claim for Trastuzumab.
Owning a law firm, the 53-year-old Deval, who was the first woman to be a partner at one of the oldest law firms in Asia – Crawford Bayley and Co – decided to fight for coverage of a therapy that could save lives. In her plea before the IRDAI (Insurance Regulatory and Development Authority of India), she argued that the reasons given for rejection were inconsistent with the insurance company’s own circular, which suggested that adjuvant therapy was payable if part of the main hospitalisation. She also pointed out the misunderstanding by medical officers regarding the nature of treatments like hormonal therapy, adjuvant therapy and immune modulators, which may not require 24-hour hospitalisation.
The insurance provider rejected her claims, saying that “Trastuzumab therapy given standalone is not covered as it is an immune modulator and not chemotherapy drug and this procedure is not covered under standard list of day care procedures.” However, it’s an injection that does not require 24 hours of hospitalisation. She, in fact, put in submissions from her doctors and an expert from Tata Memorial Hospital, who is a part of the ICMR committee on breast cancer treatment guidelines, to show that the treatment is a gold standard for cancers like hers.
When the targetted therapy is taken along with chemotherapy, then there is a likelihood of claims getting accepted. In the end, Deval could avail 50 per cent of the claim.
What a cancer insurance plan shoul look like
Deval recommends choosing a good agent who can get you through the claim process. “Confirm that the policy covers cancer if diagnosed for the first time, 30 (or 90) days after the policy commencement. Date of diagnosis is important. Make sure that all of your existing illnesses are properly recorded in the policy. There must not be exclusions like immunotherapy or targetted therapy in the cancer cover,” she says.
Next, one should vet each subhead. Hospital stays should include room charges, nursing and other medical services. Check for chemotherapy and radiation therapy sessions. “It should cover surgery-related expenses, cost of medication prescribed during cancer treatment and medical expenses before and after hospitalisation. There should be reimbursement for ambulance charges,” says Deval.
Upon diagnosis of cancer, the insured should receive a lump-sum amount to cover immediate expenses or additional costs not covered by regular health insurance.
“Some policies offer a premium waiver if the insured is diagnosed with cancer while the policy is still in effect. This means the insured won’t have to pay premiums during the treatment period,” adds Deval.
Coverage for all cancer stages
A good cancer insurance plan should cover all stages of cancer, not just early-stage detection. “Look for policies that have a wide network of hospitals where you can avail cashless treatment. Cashless claims simplify the process and reduce financial burden during treatment,” adds Deval.
Some policies may offer additional benefits such as cumulative bonus, which increases the sum insured for every claim-free year. She suggests considering policies that cover day care procedures related to cancer treatment. “Remember to compare different cancer insurance plans before choosing your own,” Deval advises.
What to do if the insurance company is not paying?
“At the first instance, file a complaint with the grievance cell of the insurance company. If they reject your claim again, then file a review application with the insurance ombudsman appointed by the IRDAI,” says Deval.
These days Deval is also counsellor and reminds women not to miss out on screenings. In fact US trials show there was a 33 per cent decrease in death from breast cancer in women older than 40 who undertook regular mammograms.
