Taiwan Insurers Find Home Chemotherapy Policies Unclear, Hampering Claims Assessment

Taiwan's life insurance association has expressed concerns regarding the lack of clear policies for home-based chemotherapy, stating that this ambiguity makes it challenging to evaluate insurance claims. The association pointed out that home chemotherapy involves significant risks, including the patient's potential inability to self-care, the hazardous nature of handling chemotherapy drugs, and the necessity for robust emergency medical support and proper disposal of medical waste.

These concerns arise as Taiwan's healthcare system explores new models of care, such as the three-person nurse-to-patient ratio policy and home-based acute care. The life insurance association affirmed its support for these initiatives, recognizing their aim to balance patient safety with efficient use of medical resources and adaptation to medical advancements. However, they stressed that the specifics of home chemotherapy policies remain unclear, hindering the insurance industry's ability to assess their applicability.

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Home chemotherapy involves the patient's poor self-care ability, high risk of chemotherapy drug handling, and the need for corresponding emergency transfer and home medical waste recycling mechanisms to ensure the safety of patients receiving treatment at home.

The association clarified that while commercial health insurance policies are long-term contracts not easily altered by policy changes, insurers have historically adapted by developing new products aligned with medical progress. Many existing policies, including cancer and targeted therapy plans, do not strictly require hospitalization and often cover outpatient procedures. They advised the public to review and update their insurance policies accordingly.

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Commercial medical insurance policies are often long-term contracts and cannot be arbitrarily changed due to policy changes, but in practice, commercial insurance has developed new products in line with medical progress.

Furthermore, the association noted that insurers retain discretion in evaluating certain coverage items that may be affected by evolving medical technology or policy shifts. This is contingent upon the existence of a premium payment and the assumption of risk. To address situations where policy terms might not explicitly cover new treatment modalities, the association issued guidance in March allowing insurers to make equitable assessments for treatments that are "alternative" and "equivalent" to covered procedures, provided they fall within the policy's scope of benefits.

The association also addressed concerns about premium rates, stating that statistics show no decrease in total inpatient days and a continued rise in surgical procedures. This indicates increased medical utilization, which could potentially lead to insufficient premiums rather than overcharging. They warned that allowing inpatient benefits for home treatment, if it leads to reduced harm, could incentivize financial motives and inappropriate medical seeking behavior. The association is collaborating with regulators on developing policies for new products like home-based acute care.

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In cases where the disease falls within the scope of benefits and meets the conditions of 'alternative' and 'equivalent,' insurance companies may adopt agreements or lenient interpretations to provide benefits comparable to those for equivalent surgical procedures within the policy terms.