Is oral chemotherapy eligible for cashless insurance claim? | Mint

My wife has been diagnosed with Glioblastoma (brain cancer). After surgery and radiation, her doctor has prescribed Temozolomide for five days as part of chemotherapy which will continue for 9 -12 months. Unlike other chemotherapy treatments that require hospitalization and allow for cashless claims, this medication—costing around ₹40,000 per month—does not require hospital admission. Given that hospitalization is not needed, will my insurer cover the cost of this medication as part of cancer treatment?

– Name withheld on request

Brain cancer, particularly Glioblastoma, requires a multi-step treatment approach, including surgery, radiation, and chemotherapy. 

Temozolomide (TMZ) is a widely prescribed chemotherapy drug used post-surgery and radiation to slow cancer progression. Many patients are unaware that oral chemotherapy like Temozolomide is covered under health insurance policies due to special provisions set by the Insurance Regulatory and Development Authority of India (Irdai) under modern therapy guidelines.

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In 2019, Irdai mandated that all health insurers must cover advanced and modern treatments under health insurance policies. According to Clause 12 of Irdai’s Standardization Guidelines, health insurance must include coverage for modern treatments such as oral chemotherapy, targeted therapy, immunotherapy, and robotic surgeries. This means that even if hospitalization is not required, oral chemotherapy like Temozolomide is eligible for reimbursement.

While Temozolomide is covered, it is important to review your insurance policy to check if there is a sub-limit. Some policies cap the reimbursement amount for modern treatments by specifying a percentage of the sum insured that can be claimed. This varies from insurer to insurer, so you should confirm the exact limit applicable to your policy.

Since oral chemotherapy does not require hospitalization, insurers typically process claims on a reimbursement basis rather than a cashless facility.

Here’s how you can claim reimbursement for Temozolomide:

Obtain a valid prescription from the oncologist specifying the requirement for Temozolomide.

Keep the original pharmacy bills and ensure they are duly stamped and signed.

Submit a claim request to your insurance provider every month along with the prescription and bills.

Include a doctor’s certificate stating that the treatment is part of standard cancer care to avoid claim rejections.

Follow up with the insurer for approval and disbursement.

Ideally you should get the claim within 30 days for filing the same.

Shilpa Arora is co-founder and chief operating officer at Insurance Samadhan.