pLOG

2025-10-07

The Shift in Cancer Treatment Models and the Challenges in Insurance Reimbursement

The rise of precision medicine has transformed cancer treatment from traditional inpatient chemotherapy to more precise outpatient or at-home oral therapies with fewer side effects. While this enhances patients’ quality of life, it also presents unprecedented challenges for insurance plans that have historically relied on hospitalization as the basis for coverage.

1. Gap Between Medical Costs and Insurance Reimbursement

Although Taiwan’s National Health Insurance (NHI) provides basic coverage, many innovative treatments—such as targeted therapies, immunotherapies, and proton therapy—are often not fully covered, leaving patients to bear substantial out-of-pocket costs that can place a heavy financial burden on families. Data show that even the average payout from critical illness insurance, around NT$548,000, falls short compared to the tens or even hundreds of thousands of NT dollars required for these new drugs or therapies.

2. The Controversy Over the Necessity of Hospitalization

With the shift in treatment models, many therapies that previously required hospitalization can now be administered on an outpatient basis. However, insurance companies may still require proof of “medical necessity for hospitalization” to process claims, leading to increased disputes. According to one report, claim disputes related to hospitalization necessity rose by 35% compared to the previous year.

3. The Evolving Definition of Cancer

In 2019, Taiwan’s Financial Supervisory Commission standardized the payout definitions for cancer insurance, categorizing cancer into three levels: early, mild, and severe. While this reform enhanced transparency in claims, it also changed how payouts are calculated. For example, first-stage breast cancer, which previously might have received 100% of the insured amount, may now be classified as “mild cancer” and reimbursed at less than 20% of the total coverage. This means that policyholders with older plans need to reassess whether their coverage is sufficient to meet current medical expenses.

 

The Three Major Financial Risks of Cancer and Insurance Companies’ Response Strategies

After a cancer diagnosis, families face three major financial risks that cannot be overlooked:

Medical expense loss, loss of life value, and health deterioration

  • Risk of Medical Expense Loss: High out-of-pocket medical costs can place a heavy financial burden on ordinary families.
  • Risk of Loss of Life Value: If a family’s primary earner of working age is diagnosed with cancer and passes away, it can disrupt the household’s economic structure.
  • Risk of Health Deterioration: The physical and mental impact during treatment may result in long-term inability to work, or the need to hire caregivers, with cumulative financial losses potentially exceeding the direct medical costs.

Facing these challenges, and guided by policy, insurance companies have begun adjusting their product strategies, introducing innovative plans that better meet evolving needs:

1. Enhancement of Critical Illness Insurance

Insurance companies are promoting lump-sum critical illness policies to reduce claim disputes and administrative costs. These plans provide a substantial one-time payment, allowing patients to access funds quickly at the early stages of a cancer diagnosis and use them flexibly for various treatment needs.

2. Fragmented or Specialized Insurance Plans

To address the limitations of traditional policies, the market has introduced “fragmented” insurance plans targeting specific high-cost out-of-pocket items, such as:

  • Cancer Genetic Testing Coverage: Provides a one-time payout, reducing the need for multiple biopsies and saving both time and physical effort.
  • Cancer-Specific Particle Precision Radiotherapy Insurance: Offers fixed payouts for high-cost treatments such as proton or heavy ion therapy.
  • Cancer Da Vinci Surgical Expense Insurance: Specifically covers the costs of high-precision surgical procedures.

3. Emergence of Innovative Insurance Products

To cover a broader range of high-risk groups, the insurance market has also introduced innovative products, such as:

  • Substandard or High-Risk Health Insurance: Designed for individuals with weaker health or existing chronic conditions, featuring more lenient underwriting criteria.
  • Post-Cancer Insurance: Specifically designed for cancer survivors, providing coverage for recurrence, metastasis, and subsequent treatments, overcoming the limitations traditionally imposed on pre-existing conditions.
  • Property & Casualty Insurance for Cancer Drugs/Treatments: Offers one-year coverage with simplified claims procedures, catering to clients with specific treatment needs.

 

Building a Comprehensive Cancer Protection Network

In today’s evolving healthcare landscape, a single insurance product can no longer provide comprehensive coverage. PatientsForce recommends that a complete cancer protection network should combine multiple products to form a robust shield of protection.

  • Basic Coverage: Choose NHI-linked critical illness insurance as a safety net, providing a one-time full payout to give patients sufficient flexibility to manage initial medical expenses.
  • Medical Expense Coverage: Complement with high-deductible indemnity insurance to cover substantial outpatient and inpatient medical costs, particularly as outpatient chemotherapy and at-home oral therapies become more common, effectively filling the gaps left by traditional insurance.
  • Cash Flow Protection: Provide a lump-sum cancer payout, offering flexible funds that can be used for the most effective treatment options and to offset income loss due to inability to work.
  • Long-Term Care Coverage: Consider disability assistance insurance, which provides ongoing payments to support long-term care needs and bridge the financial gap caused by loss of earning capacity.

 

From Passive Claims to Proactive Planning

Currently, many Taiwanese face issues such as “age misconceptions,” “insufficient financial preparation,” and “incorrect sequencing of coverage planning.” The average medical expense gap reaches NT$1.12 million, indicating a general lack of awareness of the long-term financial pressures associated with cancer as a chronic disease.

To reverse this situation, insurance planning must keep pace with the times, conducting regular “policy health checks” to help patients and their families review coverage and ensure that protections can meet the demands of an ever-evolving healthcare environment.