CHENNAI: There’s always been dialogue and discussion around bringing mental ailments under the scope for health insurance coverage, particularly after the passing of the Mental Health Care Act of 2017 and the aftereffects of the pandemic. However, despite bringing active laws and provisions, the implementation is still a work in progress at a snail’s pace.
Throwing light on the ambiguity and reiterating the scope for improvement was an educative panel session presented by the Schizophrenia Research Foundation titled ‘Mental Health Insurance Elusive or Inclusive?’ on National Insurance Day (June 28). The hour-long interaction was moderated by Dr Mangala, assistant director, SCARF, and A Chiranjeevi, research assistant, SCARF.
The panellists comprised Dr J Meenakshi, consultant ophthalmologist; Narjis Hussain, freelance writer; Sanjay Pinto, advocate; TK Muthu, administrative officer, New India Insurance; and Dr Bhagyam Raghavan, senior consultant, radiology. “We’re using this platform not to point fingers at the existing gaps but to see how we can achieve an acceptable solution that’s beneficial for all the stakeholders in the long run,” began Dr Mangala.
The long road ahead
Offering a ground reality of the mental health status in India, the discussion drew attention to the National Mental Health Survey (2015-2016) by the National Institute of Mental Health and Neuro Sciences. The study revealed that over 80 per cent of persons with depression, substance abuse, or anxiety disorders do not have access to healthcare. While stigma and lack of awareness among the general public always topped the list of reasons, a crucial factor that continues to loom large in front of them is the skyrocketing cost of treatment.
Adding to the distress of patients and their kin, a dearth of mental health professionals in the government sector has only been pushing people to opt for private hospitalisation. A family seeking help for mental health disorder nearly spends Rs 1,000 to Rs 1,500 every month on travel, besides other intangible costs that are not covered. Another study by the World Health Organization found that out-of-pocket expenditure is as high as 62 per cent in India and 32 per cent compared to the global status.
Dr Meenakshi, who struggled to get a health insurance cover when she revealed that her niece had a mental illness and was on treatment, shared, “My niece suffers from a chronic psychiatric illness. Despite having normal parameters on her master health check-up in the past consecutive years, insurance companies refused to provide a cover. I was perplexed and helpless.” Responding to this, Sanjay explained, “All insurance companies that do not cover mental illnesses are in violation of section 21 (4) of the Mental Health Care Act 2017 and Insurance Regulatory Development Authority of India’s circular number 128 dated August 16, 2018.
The IRDAI should supervise the functioning to ensure there is no discrimination. The right to medical care is every citizen’s fundamental right under Article 21, and Article 15 prohibits any kind of discrimination. The companies must be in sync with the law of the land or be liable for contempt of the court. Insurance companies don’t seem to be aware of this.” There’s not much progress even after the Mental Health Care Act came into force in 2018, points out Narjis from her experience of interacting with the stakeholders. “I remember a case where a patient of renowned psychiatrist Dr Harish Shetty was suffering from severe depression and was undergoing treatment at a private hospital.
A doctor herself, she has rejected an insurance claim. Dr Harish took up the issue with IRDAI. When I was following up on this for an article, I spoke to top officials of insurance companies and they said they were not aware of policies that covered mental illnesses. According to psychiatrists, 50-75 per cent of hospitalisation claims filed for insurance coverage are found to be rejected. Clients also seldom follow up. This being a high-profile case, fought by a doctor, got justice. But what about the general public?,” she asked.
Mental health matters
On September 30, 2019, IRDAI issued guidelines which barred the exclusion of “mental illnesses, stress or psychological disorders, behavioural and neurodevelopmental disorders” from health insurance policies. Despite this, only a handful of insurers have compiled with the guidelines. Explaining his case, TK Muthu said, “All general insurance policies started including mental health treatment under scope for coverage only after April 2021. We ask the clients to produce results of full body check-ups to keep a tab on their health ailments and transparency from their end. Some policy clauses specify that a customer cannot claim for mental health hospitalisation for the first four years of the coverage period.”
Contradicting this, Sanjay opined, “The very basis of any insurance policy is the doctrine of utmost faith. Very often it’s the insurance company that throws the hapless rulebook onto the patient. Nobody knows if a condition like dementia is preexisting or not. So prior disclosure does not work in all cases. How many insurance agents who claim commissions for every policy explain the policy fine print to the customers? People take an insurance policy with a legitimate expectation that they will be bailed out on a rainy day. Insurance companies must be transparent and exclusions must be explained carefully. It must be made easy and less cumbersome for a common person.” The National Consumer Disputes Redressal Commission has also clearly said that when there’s ambiguity in the interpretation of an insurance clause in the policy, the benefit should go to the customer.
Most insurance covers only in-patient treatment for a few days forcing patients to drop out of treatment because of the prolonged expenses. “Policies must be citizen, patient, and customer-friendly. We say we are a welfare state. Pandemic was an example. Insurance is a necessity today and we need to overhaul the way insurance works,” reiterated Sanjay. Chipping in, Dr Bhagyam added, “There’s no reimbursement for non-hospitalisation treatment, rehabilitation or outpatient services. This naturally means psychological counselling and therapy also gets excluded.”
Drawing a comparison to the mental health policies of western countries, Narjis concluded, “The central government’s health scheme, Ayushman Bharat, can be availed only by families that are below poverty line and does not cover mental health treatment at private hospitals, while foreign countries provide coverage for all forms of services. These are developed countries and they are aware of the value of mental health. They also know the connection between mental and physical health, and so they spend more on people’s health. Health is a state subject in India. The government and state are not coordinating. We hope it evolves and becomes a better scheme for the coming generations.”
While it’s positive to see some insurers offering support, unless all stakeholders sit together and reevaluate the gaps in mental health insurance coverage, we may not be able to make much progress.
The laws
According to Mental Health Care Act 2017 section 21 (4), every insurer shall make provision for mental insurance for the treatment of mental illness on the same basis as is available for the treatment of physical illness.
Health insurance companies can be prosecuted under section 109 of MHCA 2017 for not following section 21 (4).
The Insurance Regulatory and Development Authority of India issued circulars in 2018 and 2020 to include mental illness under insurance coverage.
Source: SCARF
Did you know?
Self-inflicted injuries and suicide attempts are not covered by the available health insurance policies.
Recently, court litigations have highlighted the non-compliance of insurance companies in considering mental illnesses on par with physical illnesses.