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Insurer Refuses to Pay for Drug That Works on Cancer Patient As it’s Not Been Approved for a Specific Cancer

2022-04-21 , 11:08 am

Cancer has always been a hard-fought battle, especially when your own body is rebelling against itself.

For Koh Ee Ming, a 45-year-old housewife, her cancer cells proliferate from her bile duct, and have currently spread to her liver.

The Cancerous Cells

Worst still, her particular form of cancer, as rare as it already is, tested positive for a protein called human epidermal growth factor receptor 2 (HER2+), which enables it to grow more rapidly.

This malignancy is only found in 6% of bile duct cancer patients, or in simpler terms, one in 3,500 cancer cases.

Ms Koh discovered it in June 2020, though she ignored the symptoms at first, because her stomach was only bloating and there was a developing lump.

At the start, she presumed that it was a combination of overeating and little exercise because of the pandemic.

When the symptoms continued to persist, she paid the doctor a visit, who proceeded to refer her to an oncologist, fearing that it might be cancer.

His fears turned out to be true; she was diagnosed with cholangiocarcinoma, and it had reached her liver.

Presently, the cancer is at its fourth stage; Ms Koh has no way of defeating the cancer, only controlling it.

The Road of Long Treatments

Like most cancer treatments, it starts with chemotherapy.

However, the first course of treatment failed to see any remarkable results, so she moved onto the next, but it was still unable to stop the cancer’s progression.

It seemed like all hope was lost when the oncologists told her that there were no standard treatments beyond this.

For Ms Koh, who has a 15-year-old daughter, this news is devastating as she wonders if her daughter will have to grow up without a mother.

Fortunately, her oncologist, Dr Choo Su Pin, who runs a clinic in Mount Elizabeth Novena Specialist Centre, started her on a cocktail of immunotherapy to bolster her body’s immune response, and targeted therapy against her HER2+ proteins to decelerate the cancer’s growth.

This new treatment differs from chemotherapy in the sense that it doesn’t kill the cancerous cells, nor does it harm the rapidly growing cells for hair and bone marrow, which usually leads to the balding and frailness of cancer patients.

This unconventional cocktail was successful in controlling the spread of Ms Koh’s cancer.

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The Trials of Insurance

Given her medical condition, Ms Koh has an Integrated Shield Plan (IP) with Great Eastern (GE) for private hospital care, and a rider that pays a portion of the bill.

Dr Choo and Ms Koh had initially assumed that she would be insured, even if the current treatment was twice more expensive than that of chemotherapy.

To their alarm, GE refused to pay for the new drugs, which costs $8,000 per session.

The medical bill she incurred between last November and this January summed up to $86,576, of which GE paid $53,379 for the other treatments.

This meant that Ms Koh was burdened with a debt of $33,197, which she couldn’t afford to pay.

The reason given by GE is that the drug has not been approved by the Health Sciences Authority (HSA), the de facto regulator, for the treatment of bile duct cancer.

The drug she’s currently using was approved by HSA in 2018, but it was originally meant for HER2+ Breast Cancer.

In response to The Straits Times’ enquiries, a GE spokesman stated that they empathised with the customer, and they have been supporting her claims on receipts in a prompt fashion whenever it was applicable.

However, because the administered drug is only approved for the treatment of another cancer, GE denied the Ms Koh’s claim. Despite that, GE states that they are in contact with Ms Koh and following up on this matter.

Since Great Eastern is a private insurance company with their own policies, Ms Koh has no choice but to turn her head towards government subsidies, in hopes that it will alleviate her medical debt.

According to the Ministry of Health (MOH), basic MediShield Life provides some coverage, up to a monthly cap of $3,000.

Coverage by IPs, on the other hand, are subjected to their own terms and conditions.

Dr Choo was unwilling to give up on this mode of treatment for Ms Koh, so she personally called GE to explain this, sharing that there are a few case studies that show the drug’s successful use for bile duct cancer.

It makes sense to use it because it targets Ms Koh’s HER2+ protein, she said, but she couldn’t convince them in the end.

Owing to the uncommonness of bile duct cancer, no large-scale studies have been conducted on its treatments.

Dr Choo was the Chief of Gastrointestinal Cancer Department at the National Cancer of Singapore before she opened her own private clinic in 2018.

Even the Mayo Clinic, which is ranked among the top cancer hospitals in the United States, affirmed that cholangiocarcinoma is an extremely difficult cancer to treat.

Between Money and Life

Hence, the doctor and patient are left in a predicament.

Had the COVID-19 pandemic and its corresponding restrictions on drinking and its effects on the market not struck, perhaps her husband’s wine business would be doing better, and they could afford her treatment.

For Dr Choo, she’s left with a dilemma: Should she stop her patient’s medicine when it was working so well, simply because her patient didn’t have the finances to pay for it?

Doesn’t that go against the Hippocratic Oath that every doctor is sworn to, where doctors promised that they “will use those dietary regimens which will benefit my patients according to my greatest ability and judgement”?

To give a measure of how effective the targeted treatment was, Ms Koh was able to take her daughter to Australia for a short holiday in January.

But since her insurance company was not paying for the expensive treatment, Ms Koh and her doctors decided to forgo the drug for one session in January.

Ms Koh suffered for it; her cancer markers shot up by nearly 50%, and her tumour grew.

Meanwhile, Dr Choo decided to resume the original treatment in full, though she has switched to a different, and more costly HER2-targeted drug as the response to the first drug was decreasing in effectiveness.

Dr Choo hopes that the GE will pay for this drug.

And if they do, there will only be clapping and chortles involved, because the insurance company outplayed themselves. Had a cheaper alternative but refused to insure it, and now they have a bigger bill to work with. Good job.

Although Dr Choo is kind enough to allow Ms Koh to pay for her sessions in instalments, she hopes that the appeal to Great Eastern will succeed, or else her clinic will also be burdened with a big unpaid bill.

She’s running a private practice after all, and it is a business at its core.