
THIRUVANANTHAPURAM: Insurance companies are increasingly using patients’ mental health treatment records to deny them claims for unrelated medical conditions.
Treatments for conditions like depression or obsessive-compulsive disorder (OCD) are being used as reasons to reject insurance claims for procedures such as cataract or heart surgeries.
The practice has sparked opposition, especially after actor Archana Kavi shared her own struggles with a claim denial.
Hospitals known for mental health services are witnessing a wave of complaints from patients over claim denials, despite the fact that the Mental Healthcare Act, 2017, mandates equal treatment for mental and physical illnesses.
The trend not only deepens the stigma surrounding psychiatric care but also discourages people from seeking help or disclosing their mental health struggles.
While the Insurance Regulatory and Development Authority of India (IRDAI) mandated that all health insurance policies include coverage for mental health conditions starting November 2022, its implementation has been inconsistent.
Ajinas, a resident of Ernakulam, was taken aback when his mother’s cataract surgery claim was rejected.
“I took my mother for cataract surgery at a well-known hospital in Perinthalmanna. Since I was aware of the cashless claim process, I instructed the hospital’s insurance team to notify the insurance company for approval. However, when they did, the firm responded with questions about my mother’s depression history," Ajinas said.
“They kept asking about her depression treatment and ultimately denied the claim. How can a cataract surgery be denied due to depression treatment? The two are unrelated. It feels like the insurance company is intentionally trying to avoid covering a legitimate claim,” he said.
Vivek Raj (name changed) from Alappuzha faced a similar battle when his claim was rejected due to his history of bipolar disorder. Even after approaching the IRDAI, he could not get a favourable ruling.
“Mental illness is still seen as a high-risk category, so insurance policies include specific clauses related to it. If people don’t disclose their mental health history, it can lead to claim rejection during document verification,” said Dr Ushus Kumar, director of Optimus Medical Services Pvt Ltd, which conducts third-party verification for several insurance companies.
New challenge
A new challenge has emerged as insurance companies, despite the legal obligation to cover mental health conditions on par with physical issues, have created policies that complicate matters for patients.
One such policy requires applicants to prove at least a 40% mental health disability to qualify for coverage. The clause has sparked criticism from health experts, as it contradicts the intent of providing equal coverage for mental health issues.
“By linking the Mental Health Act with the Rights of Persons with Disabilities, the burden is placed on patients to obtain a certificate proving 40% disability. This is rare for mental health conditions. Patients with OCD, depression, or even stabilised schizophrenia would struggle to get such a certificate. The policy seems designed to make it difficult for people with mental health histories to access insurance coverage,” said Dr C.J. John, senior psychiatrist at Medical Trust Hospital and a member of the State Mental Health Authority.