Recently, a colleague took their mother, who had a fracture, to see a doctor and said:
“Can we use the best medications and imported steel plates? Cost is not an issue—we have insurance.”
The doctor explained that this medication has the best sample size data, and the patient’s specific cancer mutation type can only be treated with this drug. If it were ineffective against lung cancer, they would not prescribe it, as patient health is not to be taken lightly.
However, the million-yuan medical insurance explicitly states that externally purchased oncology drugs must comply with the indications approved by the drug regulatory authority, leading to the claim denial. From a third-party perspective, the drug regulatory authority aims to standardize usage and prevent abuse, doctors prioritize treatment efficacy, and insurers aim to prevent fraud. No party is at fault. Yet, reality evolves faster than written regulations, and patients ultimately bear the consequences. After negotiations, the medication was switched to durvalumab, another lung cancer targeted therapy, and the claim was approved. In other cases, claims were approved without changing medications, provided the doctor submitted sufficient documentation. Claim outcomes depend not only on policy terms but also on the insurer. As for the second drug, paclitaxel (albumin-bound), it was not on the approved drug list, making reimbursement impossible regardless of negotiations. This limitation applies not only to the case’s million-yuan medical insurance but also to well-known products like Good Health Insurance 20-Year, Blue Medical Insurance, and Changxiang’an: – They cover over 100 specialized oncology drugs and 2 CAR-T therapies, excluding off-list medications. – Policy terms explicitly require compliance with approved indications and dosages. Deviations from these requirements often lead to claim disputes. Given that million-yuan medical insurance costs as little as a few hundred yuan annually, expecting it to solve all medical challenges is unrealistic. 3. Upgrading Million-Yuan Medical Insurance Beyond basic oncology drug coverage, some products offer better external medication benefits. Here are two examples: 1. **Coverage for Anticancer + Other Medications** For instance, Zunxiang e-Sheng 2024 covers 108 oncology drugs, plus 30 rare disease medications, 15 specific imported drugs, and 10 designated disease treatments. Zunxiang e-Sheng 2024 ZhongAn Online P&C Insurance Medical Insurance Optional benefits External medication coverage View review The 10 designated drugs include human albumin and paclitaxel injections. The only concern is its non-guaranteed annual renewal. However, no cases of post-claim renewal denials have been reported, and its large policyholder base suggests stable renewal prospects. Additionally, it continuously updates to provide broader treatment options and more comprehensive drug coverage.If you are genuinely concerned about renewal issues, you can purchase a guaranteed renewal product as a supplement.
2. No Medication List Restrictions For example, the “Good Health Insurance·Long-term Medical (0 Deductible)” on Alipay, which guarantees renewal for 6 years, has no restrictions on externally purchased medications, and this is explicitly stated in the terms. However, purchases must be made at designated pharmacies. If your older version of “Good Health Insurance·Long-term Medical” is nearing expiration and you value coverage for externally purchased medications, you may consider upgrading to this product. On the other hand, “Good Health Insurance (20-year Version)” and “Good Health Insurance (Flagship Version)” have medication list restrictions, making them more suitable for those prioritizing renewal conditions. 3. No Directory Restrictions, Coverage for Externally Purchased Medications and Equipment For instance, the following two mid-to-high-end medical insurance products not only cover externally purchased medications without directory restrictions but also reimburse externally purchased medical materials and equipment, including higher-quality plates, cardiac stents, etc., achieving true “medication freedom.” Beyond medication freedom, mid-to-high-end medical insurance also provides better medical resources and healthcare services. When facing serious illnesses, most people don’t know where to go or which doctor to consult, even if they do, they often lack access to such medical resources. Mid-to-high-end medical insurance products typically have their own medical teams to help select suitable hospitals and top-tier doctors, arranging appointments, hospitalization, surgery, and reimbursement as a seamless process. These products not only address the issue of “high medical costs” but more importantly, solve the problem of “difficulty accessing healthcare.” Both of the above products feature a 0 deductible, making them relatively expensive. For more affordable options, consider versions with deductibles. For example, “MSH Enjoy Life 2023” has a 30,000 deductible, costing only 1,075 yuan annually for a 30-year-old adult. MSH Enjoy Life 2023 Dadi Property & Casualty Insurance Medical Insurance Up to 6 million coverage Includes special departments and private hospitals Mid-to-high-end medical insurance View evaluation There’s no need to worry about high out-of-pocket expenses, as this product features a “relative deductible”: portions covered by social insurance can also be used to offset the deductible. Mid-to-high-end medical insurance is relatively complex, requiring attention not only to coverage but also to the network of hospitals and the service capabilities behind them. If interested, you can click the card at the end to schedule a consultation with an advisor. As for the “indication” challenges of specialized cancer drugs, these are difficult to resolve. Even without list restrictions, there will still be “reasonable and necessary” requirements. Therefore, in such cases, it’s crucial to communicate in advance with the insurance company and doctors to avoid incurring significant out-of-pocket expenses. 4. Final Notes The principle of medical insurance has always been “basic coverage,” making it difficult to include high-quality or expensive medications.After all, the pool of resources is limited. If one person spends more, others will have less to use…
High-quality medical resources are equally scarce, accessible only to a select few. In such circumstances, those with the means should prepare adequately, such as by opting for mid-to-high-end medical insurance with better coverage. Finally, we strongly recommend having critical illness insurance. The payout from this insurance can be used as you see fit, without any restrictions, giving you more options during serious illnesses. If you wish to customize a dedicated family protection plan for yourself and your loved ones, click the card below to start planning immediately.
