Denial of insurance reimbursements for costly cancer drugs is almost as big a challenge faced by patients and their family members as expensive cancer medicines, said doctors and patients.

Insurance companies routinely deny reimbursement for new-age cancer treatments and drugs used for patients undergoing treatment at home, alleged doctors.

In many cases, cancer patients who undergo surgeries, radiation therapy, or chemotherapy, have to take immunotherapy drugs at home for long, even in many cases entire lifetime. These drugs are often costly but are not reimbursed by insurance companies.

“Many patients are forced to discontinue treatment because they cannot afford the expensive immunotherapy or targeted therapy drugs which are not reimbursed or minimally reimbursed by insurance companies in India,” said Tanmoy Mandal, consultant medical and hematologist-oncologist at Manipal Hospitals Dhakuria.

“Often the insurance companies do not reimburse medicine costs on the pretext that it is not a conventional drug but a modern therapy. However, these are not experimental but proven drugs which have shown better results and have fewer side effects than traditional chemotherapy drugs,” said Mandal.

Doctors said apart from effectiveness, lesser side effects are also important, particularly for elderly cancer patients.

“Many cancer patients, after undergoing surgery or radiation therapy have to take oral drugs at home. These are for targeted therapy or immunotherapy drugs. However, since these are taken while not being admitted at the hospital, in most cases the insurance companies do not reimburse the costs,” said Sayan Paul, senior oncologist at Apollo Multispeciality Hospital, Calcutta.

“The costs of these drugs are reimbursed only when the patients are admitted. As a result, many patients cannot continue the treatment for long. These drugs are usually prescribed to patients with stage four or advanced cancer and need to take the medicine lifelong,” said Paul.

According to him, oral drugs like Ribociclib, Palbociclib, Crizotinib and Osimertinib are not reimbursed when taken by patients at home. “The cost of these drugs varies from around ₹40,000 to ₹1 lakh per month. Without the insurance coverage, this becomes a huge burden,” he said.

“Cancer treatment causes not only emotional but huge financial burden for patients and their family members. Insurance companies have to keep that in mind,” said Paul.

A woman in her 70s was diagnosed with breast cancer and underwent surgery. Since January 2016, she has to take Arimidex 1mg tablet daily and Denosumab injection 120 every six months.

“A strip of 14 Arimidex 1mg tablets costs ₹3,435. Each Denosumab injection 120 injection costs ₹28,000. We never get reimbursement despite having a health insurance policy of around ₹8 lakh and pay an annual premium of ₹76,000,” said her husband.

Metro reported on Wednesday how many oncologists have said although the prices of minority chemoptherapy drugs have been reduced by the Centre, many widely-used drugs are still very expensive.

“In many cases we see insurance companies rejecting claims on pretext of expensive and modern drugs being prescribed. But the insurance companies should speak to the treating doctors in such cases. I never get a call from insurance companies for clarifications,” said Gautam Mukhopadhyay, clinical lead, surgical oncology at RN Tagore International Institute of Cardiac Sciences.

“Insurance reimbursement policies should be aiming at effective results of treatment,” he pointed out.

A senior official of government health insurance company said the rules do not allow reimbursement for oral medicines taken at home.

“In all treatments, such costs are not reimbursed. If the drugs are taken while being admitted or for a certain period of time pre or post-admission, then we reimburse the costs. We are bound by the regulatory authority,” said the official.

In case of modern medicines, the Insurance Regulatory and Development Authority of India (IRDAI) in 2019 had issued a circular which had a list of modern treatment methods and advanced technology that should be reimbursed by the health insurance companies.

The IRDAI list includes oral chemotherapy.

“After the circular came into effect in 2020, insurance companies started reimbursing the modern methods but only partially.

Some of the companies give 25 percent reimbursement for the cost of suchmodern drugs,” said an official of an insurancecompany.