Will Insurance or a Scheme — Pay for Trastuzumab Deruxtecan?

Not through the standard reimbursement route, but it is worth asking your hospital's scheme coordinator whether an exception or individual case approval process exists. Both PMJAY and state schemes update their package lists periodically. Your oncologist can write a clinical justification letter, and some empaneled hospitals have submitted individual cases for consideration. There is no guarantee, but the process costs nothing and the answer may differ between centres and over time.

Yes. Insurers regulated by IRDAI must give a written reason for any rejection. If you believe the rejection is incorrect, file a grievance with the insurer's internal team first. If that does not resolve it, you can escalate to the Insurance Ombudsman for your region, which is free and does not require a lawyer. Ask for the exact exclusion clause being cited, and check whether your oncologist's letter addresses the specific clinical indication the policy requires. Many rejections are reversed on appeal when the right documentation is provided.

Tell your oncologist directly. Cost is a clinical factor that affects treatment decisions, and most oncologists in India are experienced in navigating it. There may be an alternative treatment in the same drug class that is less expensive. There may also be a relevant clinical trial open at your centre that provides the drug free of charge to participants. A compassionate use route through the manufacturer exists for some patients who do not qualify for the standard PAP. Being clear about what is affordable early keeps the most options available.

That depends on the scheme and the hospital. PMJAY and state schemes typically operate on a cashless basis at empaneled hospitals for covered treatments — you do not pay upfront. CGHS reimbursement usually requires you to pay first and then claim, though some CGHS-empaneled hospitals process bills directly with the scheme office. Private insurance can work either way, depending on whether the hospital has a cashless tie-up with your insurer. Ask the billing desk at your hospital before your first infusion so there are no surprises on the day.

Most family floater policies extend cover to a spouse, children, and sometimes parents under the same sum insured. The cancer drug benefit, if it exists in the policy, usually applies to all covered family members rather than only the primary policyholder. Check the policy document for the definition of insured members and whether any dependant carries a lower sub-limit than the primary holder. Call the insurer's helpline with the policy number if the document is unclear — this question comes up often and they should be able to answer it directly.

For most scheme routes, yes — treatment must be at an empaneled centre for cashless cover. CGHS beneficiaries can sometimes obtain prior permission for a non-empaneled centre in specific circumstances, but this requires approval before treatment starts and is not guaranteed. If your preferred oncologist is at a non-empaneled hospital, ask whether a treatment arrangement with an empaneled centre is possible, or whether consultation can happen there while the actual infusion takes place at an empaneled site. Raise this early, since the paperwork takes time to process.