Treatment Rejected by the Insurer as it was Preventive in Nature

The following is a case study published in OFS Annual report:

Madam Rose underwent a Radical Mastectomy due to Breast Cancer in June 2021. During the follow up of the cancer treatment in November 2021, she was prescribed with hormonal treatment called Aromasin which blocks the aromatise enzyme (a type of protein) from
producing oestrogen. Her claim was rejected by the insurer as the prescription was meant for prevention of cancer and did not meet the policy definition of Medically Necessary and Outpatient Cancer Treatment Benefit as stated below:

i) Outpatient Cancer Treatment Benefit
a. If the Life Assured is diagnosed with Cancer (as defined in this sub-paragraph (b) below), we shall reimburse Reasonable and Customary Charges incurred for the Medically Necessary treatment of the Cancer.
b. The Medically Necessary Cancer treatment must be received at the Outpatient department of a Hospital or a legally registered cancer treatment centre for the Cancer. Outpatients’ follow up for surveillance or prevention after curative Cancer treatment or when Cancer goes into remission shall not be covered.

ii) Definitions
In this Annexure, unless we say otherwise or unless it should in the circumstances be understood differently, each of the following terms set out below shall have the following meanings:

19. Medically Necessary
A medical service, which is:
a. consistent with the diagnosis and customary medical treatment for a Disability.
b. in accordance with standards of good medical practice, consistent with current standard of professional medical care and of proven medical benefits.
c. not for the convenience of the Life Assured or the Doctor, and unable to be reasonably rendered out of Hospital (if admitted as an inpatient).
d. not of an experimental, investigational or research nature, preventive, or screening nature.
e. for which the charges are fair and reasonable and customary for the Disability; and
f. provide treatment directly related to the covered Disability

Our Findings
Based on the blood tests taken in November 2021, the results were all within the normal range with no indication of cancer recurrence or metastases. The attending doctor also confirmed that she did not have to undergo any radiotherapy or chemotherapy treatments after the surgery in June 2021 as her histopathology report revealed that all the cancer cells had been successfully removed. The attending doctor’s justification for prescribing Aromasin was to prevent and suppress the cancer cells from spreading or recurring.

The policy provision clearly states that the outpatient cancer treatment is to provide medical coverage for the duration of curative treatment only and does not cover treatments which are preventive in nature. As Aromasin’s main purpose is only to prevent the risk of cancer cells recurring, the claim was not allowed.