More than 20 cancer patients insured with Laya Healthcare were refused cover for treatment with newly developed therapies last year, said the insurer.
Laya says it makes exceptions on a case-by-case basis when customers with advanced cancer apply for cover with “outside our approved schedule”.
The company was responding to criticism of it and Irish Life in The Irish Times by leading oncologists who claim the two insurers are hiding behind lengthy process for approving new drugs and denying patients access to proven treatments.
Prof Ray McDermott and Prof John Crown separately said the two companies are forcing patients to use inferior treatments, in contrast to VHI, which approves new drugs within months of being clinically authorised by the European Medicines Agency (EMA).
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Irish Life Health says it funds treatments that have been approved by the National Centre for Pharmacoeconomics, the National Cancer Control Programme or the HSE. This process can take up to two years, longer than anywhere else in western Europe apart from Portugal.
Laya says there are times when it will approve drugs earlier than this HSE-led process, once they have been authorised by the EMA and are supported by medical evidence, “overseen by our medical advisers”.
The company says that out of “tens of thousands” of cancer-related claims in 2022, it received 33 “exceptional requests” from consultants to cover treatment “outside our approved schedule”.
“We reviewed each of these on a case-by-case basis with our clinical team and on advice of our medical advisers. Of that number, we approved more than a third of the requests.
“The remainder were not approved for a variety of reasons, including that the therapy was not approved by the EMA or that the drug combination requested had not gone through a clinical trial and so was unproven.”
“These decisions are made in the best interest of patient safety and overseen by our clinical and medical advisers.”
It pointed out that it approves a drug such as pembrolizumab “for certain cancers” and that approval can depend on what stage the patient’s cancer is at.
The Irish Cancer Society says the inequity between what different private healthcare providers will cover and when is “just one feature of a wider system that is not working for patients”.
“There is inequity between Irish patients and patients in other European countries more than who get access to drugs faster,” said director of advocacy Rachel Morrogh. “There is inequity between the speed public patients can get access to the newest cancer drugs and those with private health insurance.”
“There is even inequity between patients covered by the same provider – some patients are on gold-plated health insurance and others are on more basic levels of cover.”
“Imagine being a patient in any of these situations and being told that the treatment your doctor recommends is not available to you. The whole system needs to be examined.”
Last February, Minister for Health Stephen Donnelly published a report by Mazars consultants which found the HSE’s drug reimbursement process was delivering results “in keeping with international norms”.
Mr Donnelly promised to introduce greater transparency to the process and to set up a working group to review the reimbursement system for new medicines.
The composition of the group has yet to be announced.
