When corporate lawyer Deval Patel was diagnosed with HER2-positive breast cancer, one that responds to targetted therapy well with the life-saving medication, Trastuzumab, she was shocked when her insurance company denied her claims despite its promised cancer coverage.
“That’s when I realised that a knowledge of insurance was most important,” says Deval, who managed to get 50 per cent reimbursement after a long fight. Her case demonstrates how we may be caught unawares by insurance companies who make you think you are secured for therapy when they couch gaping holes with smart wordplay and clauses.
Overlooking the fine print
Trastuzumab (sold under the brand name Herceptin among others), is a monoclonal antibody that’s a gold standard therapy as 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. Owning a law firm, the 53-year-old Deval, 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. When the targeted therapy is taken along with chemotherapy, then there is a likelihood of claims getting accepted. “I had to place submissions from all my doctors,” says Deval.
What your ideal cancer insurance plan should 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. The 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.
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 and cashless benefits
A good cancer insurance plan should cover all stages of cancer, not just early-stage detection. “Some insurers also specify the amount payable at each stage of detection, which is crucial to note. 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 are types of cancer covered?
Not all health insurance plans cover all types of cancer by default. “Even cancer-specific insurance plans have a predetermined list of covered cancers defined by the insurance company. It’s essential to check the list of exclusions to ensure that any cancer of personal concern is not omitted from coverage,” says Deval.
What to do if the insurance company is not paying?
“First, file a complaint with the grievance cell of the insurance company. If the claim is rejected, then file a review application with the insurance ombudsman appointed by the IRDAI,” says Deval.
If you have regular insurance, can you add cancer insurance?
You can always add a top-up plan from your own or another insurance company to your existing policy. Deval suggests a look at the following causes:
1) Standalone Cancer Insurance vs Regular Health Insurance: Most regular health insurance plans in India already cover hospitalisation expenses related to cancer treatment. This coverage may be part of the base policy or offered as add-on riders. However, these plans might not cover all non-hospital expenses associated with cancer treatment. For comprehensive coverage, you can explore specific cancer insurance plans that provide wider coverage specifically for cancer treatment.
2) Lumpsum Payment vs. Reimbursement: The amount payable by the insurer can be either a one-time fixed lump sum paid upon diagnosis (common in most cancer insurance plans) or reimbursement of actual expenses incurred during treatment.
Watch out for coverage/benefit
Deval recommends scanning the fine print and seeing if there is any co-payment or the amount to be borne by the policyholder on the cost of cancer treatment. “Scan the sub-limits, an upper cap on the amount payable by the insurance company,” she adds.
What should your cancer insurance plan look like? A corporate lawyer tells you how to read the fine print (Representational image via Canva) 
Share
