My mother will have to undergo chemotherapy. Do I need to get insurance approval for each session?

My mother is going to undergo chemotherapy and she needs 6-8 sessions as recommended by the doctor. Do I need to get approval every time my mother goes to therapy?

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Response from Partanil Ghosh, Director and Chief Commercial Officer, HDFC ERGO General Insurance

First of all, I wish your mother a speedy recovery. In some cases, insurers may require approval of the entire treatment plan rather than each individual session. Once they agree on an initial treatment plan, you may not need to obtain additional approvals for subsequent sessions at the same hospital. In addition, some insurers provide a single authorization for all sessions at the beginning of treatment, provided that the treatment will take place in the same hospital on the recommendation of doctors. But just in case, it is recommended to consult with your insurer.

Additionally, several factors may merit your consideration when seeking approval:

Pre-authorization process: Some insurers may require pre-authorization for each chemotherapy session. This process involves submitting the necessary documents, including the treatment plan, medical reports and other relevant information, to the insurer for review and approval. It is critical to follow the pre-authorization process as recommended by your insurer.

Timely communication. Regardless of the approval process, it is critical to maintain open communication with your insurance company. Keep them informed of the prescribed number of chemotherapy sessions and ensure prompt provision of any required documentation to facilitate coverage and prevent potential delays in reimbursement.

Coverage and Policy Limitations: Check your insurance company’s coverage and limits for chemotherapy treatment. Make sure that the number of sessions recommended by the doctor falls within the coverage limits specified in the policy. If there are any restrictions, discuss potential alternatives with your insurer. In addition, there may be some exclusions for the treatment regimen, which will vary from insurer to insurer, so it is wise to check the terms of your policy in advance.

Treatment Modifications: If any changes or adjustments are made to your treatment plan during your course of chemotherapy, such as changes in medications or dosage, you must tell your insurer promptly. This allows the insurer to evaluate the changes and verify the need for additional approvals.

Emergencies: In the event of an emergency that requires immediate chemotherapy, obtaining prior authorization may not be possible. In such cases, inform the insurer as soon as possible to ensure a smooth reimbursement process.

Continued monitoring: Throughout the treatment process, it is important to keep your insurer informed about the progress of your chemotherapy sessions. This may include sharing medical reports, updates from the treating physician, and any changes to the treatment plan.

It is important to note that every insurance policy is tailored to suit the profile of the insured and therefore it is advisable to read the terms and conditions of your policy carefully. Consult with your insurer and maintain open communication to ensure that your mother’s treatment is adequately covered and the claims process runs smoothly and without problems.

(The opinions expressed by the expert are his own. Email us your questions at [email protected]. We’ll get your questions answered by our panel of experts)