On the face of it, you have two flavours of cover: cancer-only and non-cancer-included versions for chemotherapy and immunotherapy.

However, when you dig into the policy wordings, some technical terminology emerges that is deeply concerning.

Specifically, that wording is "MedSafe indicated", which, on the face of it, most of us, and the public, will say; Yeah, the medication needs to be listed for the treated condition.

However, that's not the whole story.

That "indicated" term is a technical clinical term, and relates to the specifics of the medicine's use, including conditions of use that likely make no sense to the average person on the footpath.

Generalising: everyone knows cancer treatments are only effective for so long, where the more aggressive cells survive, and a new treatment is needed to control cancer.

This is where "MedSafe indicated" in policy wordings, comes into play. It significantly limits access to treatment under most current medical policies.

Four out of the big five current medical policies will not fund all of your MedSafe-approved cancer treatments, as you expect.

Those four you need to be mindful of: Accuro, AIA, nib, and Southern Cross.

This is because phrases like "indicated first-line treatment" in MedSafe guidelines mean the medication is only authorised for use as THE first treatment for THE condition.

MedSafe approvals for medicines also include a range of other constraints or use guidelines, which are what the "MedSafe indication" in policy wordings refers to.

If a patient has had cancer treatment that has stopped working and the oncologist wants to use a different medication that has this "first-line" criteria, then it's not MedSafe approved for that use, and four out of five insurers won't pay the bill for it.

Partners Life has a similar first check with its wording, but it is the only insurer with alternative assessment criteria to approve use outside the MedSafe criteria.

To be clear, I am viscerally angry about insurers' use of nuanced minutiae to avoid claims. This level of omission of information and mechanics is not in line with our good faith expectations of insurers and behaviour like this deeply impacts our faith in them.

We advisers are the meat in the sandwich here. The insurers are under informing us of the details involved in claim management and setting us alight with "unfunded cancer medications are covered." Knowing full well that when we get down to the detail, the insurer can wriggle out and avoid paying these claims.

Which is likely to leave us facing the music with a professional complaint about misleading or inaccurate advice to clients impacted.

I understand that these medicines are expensive, at the same time, they are also part of the intended coverage.

It is up to the insurer to ensure that the policy is fit for purpose, reasonably priced and that they act in good faith when it comes to claims.

Given that thousands of medicines MedSafe approved and not funded by Pharmac are now available, the lack of guaranteed policy wordings for many medical policies will be an interesting discussion in the future as more pressure comes to bear on this area.

I'll come back to my point on omission by the insurers.

If the client impacted here, and the others I have since been made aware of by many people and clinical providers, had known the full story of what claims would do when presented with a claim for follow-up treatment, they would have likely taken a different approach with their treatment.

* This is also a concern for clinicians advising patients, as treatment funding has a significant impact on treatment success.

If the client here had known, or the clinician had advised their patient, that the options presented they choose from could have a different response from claims, they would have likely taken a different route.

In this case, the client was presented with three options. They chose the most aggressive approach, which was Pharmac funded.

They are dealing with stage 4 cancer, and their oncologist knows they are not surviving this; treatment is only extending life.

This means they know full well that this is not a one-and-done thing and other treatment(s) will follow.

If the client knew what they know now, they would have potentially taken the unfunded "MedSafe indicated, first-line treatment" and had this paid for by their insurer.

Knowing that the patient's insurer will pay for the subsequent treatment being funded by Pharmac without question or games on MedSafe guidelines. Because Pharmac-funded trumps MedSafe guidelines with claims.

If you are an adviser or clinician, please spread the word by sharing this article.

Upfront, informed patients navigating this will make better decisions on their treatments, and insurers will lose their ability to be difficult on our most sensitive claims.

The questions for clients to ask their clinicians:
* What medications are funded by Pharmac?
* What medications are not funded by Pharmac?
* Of the medications not funded by Pharmac, what are the MedSafe guidelines and criteria for use?

Where the MedSafe indication is first-line, these medicines must be considered for use first. If you don't use them first, your insurer is unlikely to approve them for use later.
* Where the MedSafe indication is for use after trying XYZ treatment, that guideline on use must be followed.

Yes. This will interfere with the clinician's preferred approach as the medical professional best qualified to advise their patient.

Yes. This is an American claims management style that is creeping into our market.

No, I'm not happy about this. It is an underhanded omission-based approach that is impacting people's lives at a time when they least need it!

To those four insurers: Do Better!