Health Insurance Laya's poor coverage for cancer treament

C

Curlyfella

Registered User
Messages
82
elacsaplau said:
Hi Poka,

I agree with you and empathise. Personally, I find the disclosure from LAYA and other health insurers to be very poor.

Our family plan is through my wife's work with Irish Life Health. We get all this nonsense each year - the most egregious part being some form of "reasons why" letter which starts off with something like...…"having considered your personal situation, etc., we recommend the blah, blah policy for you, etc., etc."...………...IT'S A GROUP POLICY!!…….has everyone in my wife's work got identical needs to us??!!……...and precisely what review did they do on us??!!

In the case of LAYA, if anyone thinks that they are covered for cancer, be careful. LAYA claims to cover chemo but in my experience (via a close friend a while back)…..what LAYA means is that it covers certain forms of chemo but not others - but in any reasonable reading of the point of sale material, this distinction is, not at all, made clear.

[To elaborate, when diagnosed with stage iv cancer, part of one's hope is that some new drug will come along that will reverse the anticipated trajectory of the disease. New drugs do come along which can be of great benefit including extending lifespan and dramatically improving the quality of life. This drugs are proprietary, in huge demand, the outcome of massive R&D, etc. and as a consequence likely to be very expensive. My friend thought that he would be covered for one such drug but he wasn't. They were apparently too new, too high-tech. What's really bad is that some people will not be able to afford the correct treatment. The "too new" bit is really deplorable because without substantial means, the impact will be that if, the much hoped and prayed for, new drug does come along...……...Mr. Ordinary may not be able to afford it personally and his insurance won't cover it.]

The specific questions that I would like to know are:

1. What precise disclosure requirements health insurers are obliged to follow?

2. Can anyone show me anywhere in LAYA's communications which addresses the OP's concern and my concern in relation to cancer drugs? Specifically, where in the point of sale material was the OP advised the his/her psychotherapy fees would no longer be covered? And where in relation to chemo treatment is it made clear that certain therapy will be covered and other therapy denied? [For the avoidance of doubt, the chemo in question was recommended by his oncologist and is considered international best practice therapy as he used an "international second opinion service."

3. What is the independent redress channel / arbitrer in relation to health insurers? Is it the FS&PO?
Click to expand...


There is a story about this exact thing below - Laya refused the cover but were pressured by a TD and now have said they'll cover for 3 months.
€150,000 price tag for Quin woman’s vital cancer treatment

https://clarechampion.ie/e150000-price-tag-for-quin-womans-vital-cancer-treatment/

Quin woman secures cover for break-through treatment after public campaign

https://clarechampion.ie/quin-woman-secures-cover-for-break-through-treatment-after-public-campaign/


is there anywhere to find out exactly what is and is not covered for your policy?
 
Thanks Curlyfella,

That's very intereting. As I asked previously,......

elacsaplau said:
....where in relation to chemo treatment is it made clear that certain therapy will be covered and other therapy denied? [For the avoidance of doubt, the chemo in question was recommended by his oncologist and is considered international best practice therapy as he used an "international second opinion service."]
Click to expand...

In the first of the two linked articles,

A statement from Laya said the company covers Pembrolizumab, “for members being treated for certain cancers in line with clear guideline from the National Cancer Control Program”.

“Achieving the best patient outcome for our members is at the heart of our decisions when it comes to covering cancer treatments and services,” the statement said. “Laya Healthcare accepts the guidance and direction of the National Cancer Control Programme (NCCP), the National Centre for Pharmaeconomics (NCPE) and the HSE in respect of best practice guidelines for cancer treatment, adopting their policies where appropriate to ensure the best outcome for our members.”

Loads of questions arise like....

1. How is a member meant to know if his specific recommended cancer treatment will be covered? [Remember advanced cancer is more and more being treated by targeted therapies. If I discover that I have advanced cancer in, say, 7 years' time, there's a reasonable chance that the best therapy hasn't even been developed yet.]

2. Where does a member advised (in any communication/material from LAYA) that payment of cancer treatment is depended on advices from the NCCP, the NCPE and the HSE?

3. What happens if there is a difference of opinion between the NCCP and the NCPE? [What are the views of the NCCP and NCPE anyway - are they to do with "best patient outcome" as LAYA claims in it statement above or are these views more to do with which drugs are deemed to provide sufficient value for money to justify payment from the public purse?]*

4. If someone is with LAYA, what plan level would need to be purchased in order to ensure that following a cancer diagnosis that all treatment recommended by his oncologist would be covered? (Think about this last question everyone!).

*Of course, it's when drugs are not paid from the public purse that one really needs one's supplementary/top-up/private insurance to kick in!!
Also, for the avoidance of doubt, I understand the rationale for the NCCP and the NCPE - this thread is about LAYA presenting arguments in denying claims that I can not see communicated at point of sale/renewal.
 
This sounds exactly like what happened to my poor husband. We couldn't afford the treatment he needed and LAYA wouldn't pay even though they give the impression that they cover chemo. The treatment that was recommended wouldn't have saved his life but it probably would have extended it a bit and it would also have probably meant that the quality of his life in his last 12 to 18 months would have been much better.
 
SGWidow said:
This sounds exactly like what happened to my poor husband. We couldn't afford the treatment he needed and LAYA wouldn't pay even though they give the impression that they cover chemo. The treatment that was recommended wouldn't have saved his life but it probably would have extended it a bit and it would also have probably meant that the quality of his life in his last 12 to 18 months would have been much better.
Click to expand...

That is just awful. So sorry to hear this.
 
elacsaplau said:
Thanks Curlyfella,

That's very intereting. As I asked previously,......



In the first of the two linked articles,

A statement from Laya said the company covers Pembrolizumab, “for members being treated for certain cancers in line with clear guideline from the National Cancer Control Program”.

“Achieving the best patient outcome for our members is at the heart of our decisions when it comes to covering cancer treatments and services,” the statement said. “Laya Healthcare accepts the guidance and direction of the National Cancer Control Programme (NCCP), the National Centre for Pharmaeconomics (NCPE) and the HSE in respect of best practice guidelines for cancer treatment, adopting their policies where appropriate to ensure the best outcome for our members.”

Loads of questions arise like....

1. How is a member meant to know if his specific recommended cancer treatment will be covered? [Remember advanced cancer is more and more being treated by targeted therapies. If I discover that I have advanced cancer in, say, 7 years' time, there's a reasonable chance that the best therapy hasn't even been developed yet.]

2. Where does a member advised (in any communication/material from LAYA) that payment of cancer treatment is depended on advices from the NCCP, the NCPE and the HSE?

3. What happens if there is a difference of opinion between the NCCP and the NCPE? [What are the views of the NCCP and NCPE anyway - are they to do with "best patient outcome" as LAYA claims in it statement above or are these views more to do with which drugs are deemed to provide sufficient value for money to justify payment from the public purse?]*

4. If someone is with LAYA, what plan level would need to be purchased in order to ensure that following a cancer diagnosis that all treatment recommended by his oncologist would be covered? (Think about this last question everyone!).

*Of course, it's when drugs are not paid from the public purse that one really needs one's supplementary/top-up/private insurance to kick in!!
Also, for the avoidance of doubt, I understand the rationale for the NCCP and the NCPE - this thread is about LAYA presenting arguments in denying claims that I can not see communicated at point of sale/renewal.
Click to expand...

Would the health insurance authority be able to clarify these type of things?

https://www.hia.ie/


Theres also a man by the name of Dermot Goode who seems to be the only person in this country that can help to navigate policies.


https://www.totalhealthcover.ie/
 
Hi Curlyfella,

The HIA, as I understand it, mostly provides information as it name suggests.

The Regulator of LAYA is our old friend the Central Bank - 'nuff said. Aggrieved policyholders can take their case to a genuine friend, the FS&PO.

Just some comments regarding expert commentators on health insurance.

1. Dermot Goode has certainly a public profile but there are others. I have not heard any commentator publicly criticise the insurers in this regard.

2. I have huge respect for a regular user of AAM called Snowyb who has been incredibly generous with his time and expertise. I see that he hasn't posted for a few months - I hope that he is ok. It would be great to get his views on these matters.


SGWidow said:
.......even though they give the impression that they cover chemo.
Click to expand...

Hi SGWidow,

As Curlyfella said above, this is awful and I totally agree that LAYA does not make clear at the point of sale which chemo it does and doesn't cover. I suspect that my questions haven't got traction because most people are in the happy position of not being aware of these restrictions.
 
I am
elacsaplau said:
Hi Poka,

I agree with you and empathise. Personally, I find the disclosure from LAYA and other health insurers to be very poor.

Our family plan is through my wife's work with Irish Life Health. We get all this nonsense each year - the most egregious part being some form of "reasons why" letter which starts off with something like...…"having considered your personal situation, etc., we recommend the blah, blah policy for you, etc., etc."...………...IT'S A GROUP POLICY!!…….has everyone in my wife's work got identical needs to us??!!……...and precisely what review did they do on us??!!

In the case of LAYA, if anyone thinks that they are covered for cancer, be careful. LAYA claims to cover chemo but in my experience (via a close friend a while back)…..what LAYA means is that it covers certain forms of chemo but not others - but in any reasonable reading of the point of sale material, this distinction is, not at all, made clear.

[To elaborate, when diagnosed with stage iv cancer, part of one's hope is that some new drug will come along that will reverse the anticipated trajectory of the disease. New drugs do come along which can be of great benefit including extending lifespan and dramatically improving the quality of life. This drugs are proprietary, in huge demand, the outcome of massive R&D, etc. and as a consequence likely to be very expensive. My friend thought that he would be covered for one such drug but he wasn't. They were apparently too new, too high-tech. What's really bad is that some people will not be able to afford the correct treatment. The "too new" bit is really deplorable because without substantial means, the impact will be that if, the much hoped and prayed for, new drug does come along...……...Mr. Ordinary may not be able to afford it personally and his insurance won't cover it.]

The specific questions that I would like to know are:

1. What precise disclosure requirements health insurers are obliged to follow?

2. Can anyone show me anywhere in LAYA's communications which addresses the OP's concern and my concern in relation to cancer drugs? Specifically, where in the point of sale material was the OP advised the his/her psychotherapy fees would no longer be covered? And where in relation to chemo treatment is it made clear that certain therapy will be covered and other therapy denied? [For the avoidance of doubt, the chemo in question was recommended by his oncologist and is considered international best practice therapy as he used an "international second opinion service."

3. What is the independent redress channel / arbitrer in relation to health insurers? Is it the FS&PO?
Click to expand...
Hi Elacsaplau
I’m saddened to hear of your friend as Laya have also refused to cover a targeted therapy for me . The results of genetic testing showing a high percentage of success against my cancer made little difference . Totally agree that Laya cancer cover is very poor .
 
I'm with Laya, simple connect, my policy due for renewal soon, I'm going to ask.about this before renewal.
 
Does anyone know whether thIs cover* is provided by analogous plans in VHI?
*[For the avoidance of doubt, the chemo in question was recommended by his oncologist and is considered international best practice therapy as he used an "international second opinion service."]
thanks
aj
 
WhiteCoat said:
Can someone please clarify the issue here please - is it that other insurers cover high-tech/high cost/targeted cancer chemo drugs and LAYA does not?
Click to expand...

As far as I know it's a case of only vhi covering certain cancer treatments. This dates back to early 2019 e.g. see https://www.irishtimes.com/news/hea...s-decision-on-cancer-drugs-1.3861304?mode=amp

It's not possible to get a list of what's covered because it's all evaluated on a case by case basis. The oncologist sends a report to vhi & they decide.

New treatments are emerging all the time. While these get approval at a European level, it can take a long time (often years) for a decision on whether the treatment is approved for public patients in Ireland and not all get approved by any stretch.

It is some of these treatments that vhi can decide to cover on a discretionary case by case basis.

I tried to get to the bottom of this with laya last year but did not get any answers. Vhi can be cagey on it too because it is very much case by case. The treatment costs involved can be huge & the landscape changes all the time.

But this potential treatment cover sets vhi apart & is the only reason I switched to them this year.
 
You must log in or register to reply here.
Back
Top