Claim Scenario:
Life assured has advanced melanoma and has been advised surgery is not available, and the disease is metastatic. They have been told the best option is to be treated with Keytruda (Pembrolizumab). Would you consider a claim to fund the use of Keytruda under non-Pharmac provision of the policy (or otherwise), at what stage in the progression of the disease would you consider a claim, and how much would you pay?
Insurer replies
Accuro
“Yes they would pay a claim of this nature as long as a few items check off, e.g. The melanoma is not a pre-existing condition with an exclusion. Also we would pay this under the non-pharmac benefit which is only in SmartCare+ and only up to the limit in the benefit”.
AIA
“A claim would be considered under the REAL Health Cancer Benefit Non Pharmac for Keytruda as per the Medsafe indications. These are:
- It has to be monotherapy
- The treatment is for unresectable or metastatic Melanoma
- The patient is an adult”
nib
“nib will accept the claims at any stage up on Admission. Since it is administered intravenously, we will pay it under the Ultimate Health Max “Non-PHARMAC Funded Drugs in Hospital Benefit” up to the Hospital Medical Benefit maximum of $200,000. (If it was a take-home drug, we would have covered it under the ‘Non-PHARMAC Funded Drugs at Home Benefit’ which also has the same benefit maximum.)”
Partners Life
“As Keytruda is Medsafe approved for the treatment of Melanoma, Partners Life would fund the treatments as described in your scenario, regardless of whether or not it is funded by PHARMAC. It would be covered under Partners Life’s Non-Surgical Benefit Maximum of $300,000 per person per annum, Partners Life does not restrict such treatment to being administered in Hospital (under the Private Hospital Benefit) and may be funded while being administered at home (under the Serious Illness Benefit) subject to the advice of an appropriate doctor.”
Southern Cross
“Members can claim up to $60,000 per claims year for chemotherapy and up to $10,000 for non-Pharmac approved MedSafe indicated chemotherapy drugs. Regarding treatment, as stated in the policy document, chemotherapy drugs must be Pharmac Approved to be covered under the chemotherapy benefit. If a chemotherapy drug is not Pharmac approved it may be claimed under the maximum for non-Pharmac approved Medsafe indicated chemotherapy drugs.”
Sovereign
“Sovereign will pay for Medsafe approved non-Pharmac chemotherapy drugs and cancer support services up to $300,000 per policy year under Private Health Cancer Care benefit once a diagnosis of cancer has been made. Keytruda is a MedSafe indicated drug and we’ve been paying claims for this drug, and will continue to pay for this. We also offer cover for on-going treatment, which includes post-cancer allowances up to $500 per year for support services, therapies or personal items”.