Review of Individual Health Insurance Policies for Mental Health Conditions
1–4Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
Corresponding Author: Thanapal Sivakumar, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India, Phone: +91 080 26995834, e-mail: email@example.com
How to cite this article: Singhai K, Sivakumar T, Angothu H, et al. Review of Individual Health Insurance Policies for Mental Health Conditions. Ind J Priv Psychiatry 2021;15(1):3–9.
Source of support: Nil
Conflict of interest: None
In India, 85% of healthcare occurs in the private sector. Health insurance schemes can help prevent catastrophic health expenditure and resultant “poverty trap.” Section 21 (4) of the Mental Health Care Act (MHCA) 2017 asks insurers to make provisions for treating mental illness on the same basis as is available for the treatment of physical illness. The Insurance Regulatory and Development Authority of India has required health insurance companies to comply with MHCA 2017. This paper discusses various health insurance policies available for mental health conditions and implications of a recent Delhi high court verdict for health insurance for mental illness.
Keywords: Autism spectrum disorder, Health insurance, India, Intellectual disability, Mental illness
Worldwide, healthcare expenditures impose a substantial burden on the individual and the Government.1–3 The healthcare system varies across countries from complete Government health coverage to fully privatized healthcare systems. The United Kingdom delivers healthcare to its citizens through the Government’s National Health Services funded by taxes. Other developed countries, such as Germany, France, and Australia, also provide near 100% healthcare coverage to their population.4 On the contrary, the United States of America is primarily an insurance-based healthcare system where healthcare access is based on the insurance policy purchased by the citizen, their family, or their employer.4
In most low- and middle-income countries, a significant proportion of healthcare expenditure is borne by the individual and family out-of-pocket. Ideally, the Government should bear the healthcare expenses of its citizens.5 The World Health Organization estimates that out-of-pocket expenditure on health in India is as high as 65.1% (percentage of the current health expenditure) compared to the world average of 32%.6 Every year, 3.5% of the Indian population becomes impoverished and 5% face catastrophic expenditure due to medical bills.7 Assessment of the economic cost of the care for a person with a mental illness showed that the median out-of-pocket expenditure per month was approximately ₹1,000–1,500 ($13.66–20.48).8 Healthcare expenditure is a huge burden, particularly for those belonging to the lower socioeconomic strata. Based on the level of infrastructure and care provided, the public healthcare system in India is organized as primary, secondary, and tertiary level care centers spread across more than 600 districts. Though healthcare is free in many publicly funded hospitals, 85% of medical care occurs in the private sector.8 Health insurance schemes can help prevent catastrophic health expenditure and resultant “poverty trap”9especially when the public health system does not reach every citizen. However, the concept favors those who can afford to buy a health insurance policy, unless policies are offered at highly subsidized rates by the Government.
Insurance is a contract between the insurance company and the policyholder in which an individual or entity receives financial protection or reimbursement against specified potential future losses from an insurance company.9
Health insurance works on the principle of risk pooling. It balances cost across a large, random sample of individuals. For example, an insurance company has a pool of 1,000 subscribers, each paying ₹1,000 per year. In a year, 50 people out of 1,000 may get hospitalized for illness while the others stay healthy, which allows the insurance company to use money from the larger pool to treat people who become ill and make a profit.
The registration of Indian insurance companies regulations 2000 defines health insurance or health cover “as the effecting of contracts that provide sickness benefits or medical, surgical or hospital expense benefits, whether inpatient or outpatient, on an indemnity, reimbursement, services, prepaid hospital, or other plan bases, including assured benefits and long-term care.”10
The market currently offers a range of health insurance schemes, which differ. Some significant ways they differ in are inclusion and exclusion criteria; health conditions covered; the network of hospitals; cashless treatment/co-payment clauses; and individual/group health insurance policies. The premium paid also differs according to the following factors: age, medical history, risky behavior (including substance use), and no claim discounts for previous years.7
The article covers individual health insurance schemes (public and private) that provide coverage to mental health conditions (including developmental disabilities and mental illness), which were available as of June 2021. The article excludes group policies (like central Government health scheme, employees’ state insurance scheme for employees, Rashtriya swasthya bima yojana for unrecognized sector workers and their families below the poverty line (BPL), state employees group insurance, and defense services health insurance).
PUBLICLY FUNDED HEALTH INSURANCE POLICIES COVERING MENTAL ILLNESS AND DEVELOPMENTAL DISABILITIES
The Niramaya Health Insurance Scheme was launched by the National Trust (NT) under the Government of India on March 26, 2008.11 The scheme provides insurance cover for persons with disabilities (PwD) covered by National Trust Act, 1999 (including cerebral palsy, autism, intellectual disability, and multiple disabilities). There is no age limit to avail of the scheme. The premium for NHIS is nominal, ranging from ₹50 to ₹500 per annum based on whether the PwD is below the poverty line (BPL) or not. Some State Governments, like Karnataka, pay the premium on behalf of PwD from BPL families. The sum insured is up to ₹1 lakh/-.11 More details are given in Table 1.
|Sl. No.||Name of plan||Sum insured (₹)||Important inclusions||Important exclusions||Other remarks|
|1.||Niramaya (health insurance scheme)||1 lakh
||All PwD under the National Trust Act, 1999 with valid disability certificate||PwD not covered by National Trust Act, 1999||—|
The Swavlamban Health Insurance Scheme, launched in October 2015 by the Government of India, was the first insurance policy for persons with mental illness and six other disabilities covered by the Persons with Disabilities Act 1995.7 PwD with an annual family income of ₹3 lakhs or below were eligible to avail of the scheme’s benefits. A premium of ₹357 was collected from the insured person. The scheme also covered outpatient department (OPD) cover up to ₹3,000 per annum. The scheme was stopped in 2017.7
In 2018, the Ayushman Bharat (National Health Package Scheme) was launched by the Government of India, targeting deprived families per the socioeconomic caste census data.12 The Pradhan Mantri Jan Arogya Yojana component provides cashless health insurance cover up to ₹5 lakh per family (no restriction of family size) per year. States/union territories (UTs) were advised to implement the scheme by a dedicated entity called the State Health Agency. Various states are implementing the Ayushman Bharat schemes under various names. For example, it is called “Arogya Karnataka” in the Karnataka state and includes packages to treat mental illnesses in Government hospitals.12 Biju Swasthya Kalyan Yojna of the Odisha Government also covers expenses for treating mental illness in Government hospitals.13
A few states are implementing their health insurance schemes, namely Swasthya Sathi (Government of West Bengal), Aarogyashri (Government of Telangana), and Quality Health for all (Government of Delhi) but unfortunately, none of these mentions or includes coverage for mental illness.14
REVIEW OF INSURANCE POLICIES COVERING AUTISM SPECTRUM DISORDER
|Sl. No.||Name of plan||Sum insured (₹)||Important inclusions||Important exclusions||Waiting period|
|1.||Star special cover||3 lakhs||Persons with autism spectrum disorder, aged 3–25 years.
Covers behavioral therapy, physiotherapy, occupational therapy, and speech therapy on OPD basis.
|Any hospital admission primarily for investigation/diagnostic purposes, substance abuse, and self-inflicted injuries||
|2.||Religare Care Freedom plan||3–10 lakhs||Covers autism along with other illnesses; only policy to cover persons with autism aged >25 years||Treatment of mental illness, stress, or psychological disorders. Any treatment taken in a clinic, rest home, convalescent home for the addicted, detoxification center, sanatorium, home for the aged, mentally disturbed, remodeling clinic, or similar institutions||24 months waiting period for preexisting diseases.|
MENTAL HEALTH CARE ACT (MHCA) 2017 AND INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA (IRDA) CIRCULARS ON HEALTH INSURANCE FOR PERSONS WITH MENTAL ILLNESS
For about six decades after independence, Indian insurance companies excluded treatment expenses for mental illness in individual health insurance policies, possibly due to poor awareness about mental illness and a lack of advocacy.
The Mental Health Care Act (MHCA) 2017 was a landmark moment for insurance coverage of persons with mental illness. Section 21 (4) of MHCA 2017 states, “every insurer shall make provision for medical insurance for treatment of mental illness on the same basis as is available for the treatment of physical illness.”5,19 According to Chapter 1 of MHCA 2017, mental illness “means a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behavior, capacity to recognize reality or ability to meet the ordinary demands of life, and mental conditions associated with the abuse of alcohol and drugs, but does not include mental retardation that is a condition of arrested or incomplete development of mind of a person, specially characterized by subnormality of intelligence.”19 This definition covers all mental illnesses under the F code of ICD-10 except intellectual disability.
After 1.5 years of passing the Act, the Insurance Regulatory and Development Authority of India (IRDAI) issued a circular on August 16, 2018, to include mental illness under the ambit of insurance coverage.20 On June 2, 2020, IRDAI issued a circular stating that insurance companies should comply with the provisions of MHCA 2017 and should publish on their website the philosophy and approach about covering person affected with mental illness and that the compliance should be in place by October 1, 2020.21
REVIEW OF INSURANCE POLICIES COVERING MENTAL ILLNESS
Few insurance companies have started covering mental illness over the last few months after the IRDA circulars.
The following issues need to be considered regarding health insurance policies for persons with mental illness (Table 3).
|Sl. No||Name of plan||Sum insured (₹)||Importantinclusions||Important exclusions||Other remarks||Inpatient care||OPD care|
|25 lakhs||OPD treatment
Up to 10 OPD consultations per year
Mental and psychiatric conditions:
Treatment related to symptoms, complications, and consequences of mental illness, mood disorders, psychotic, and nonpsychotic disorders, including treatment related to intentional self-inflicted injury or attempted suicide by any means.
This exclusion will not be applicable to OPD consultation and behavioral assistance programs.
|A waiting period of 36 months for preexisting illnesses; waiting period not applicable for outpatient consultations and counseling sessions||No||Yes|
|2.||Max Bupa Health Premia||5–50 lakhs||Cap of ₹50,000 on OPD claim. Sublimits as per policy schedule for severe depression, schizophrenia, bipolar disorder, post-traumatic stress disorder, eating disorder, generalized anxiety disorder, obsessive–compulsive disorder, panic disorder, personality disorders, dissociation disorders, and conversion disorders||
||Waiting period of 24 months for preexisting diseases. Waiting period for mental disorder treatment is 36 months.||Yes||Yes|
|3.||Manipal Cigna pro-health insurance||2.5 lakhs up to 1 crore||Domiciliary care for psychiatric or psychosomatic disorders of all kinds||Treatment for alcoholism, drug or substance abuse, or any addictive condition and consequences thereof.
Expenses related to any admission primarily for diagnostics and evaluation purposes. Intentional self-injury, suicide, and attempted suicide.
|Preexisting diseases will not be covered for 24, 36, or 48 months depending on the plan variant||Yes||Yes|
|4.||HDFC Ergo Health Suraksha||3–5 lakhs||Hospitalization expenses incurred for treating mental illness||Any insured person committing or attempting to commit a breach of law with criminal intent, or intentional self-injury, or attempted suicide or suicide while mentally sound or unsound.
The abuse or the consequences of the abuse of tobacco, intoxicants, or hallucinogenic substances, such as drugs and alcohol, including smoking cessation programs and the treatment of nicotine addiction or alcohol addiction programs, any other substance abuse treatment or services, or supplies.
Preventive care, any physical, psychiatric or psychological examinations, or testing if it does not require hospitalization
|Waiting period of 36 months for all preexisting conditions||Yes||No|
|5.||ICICI Lombard health shield||3–50 lakhs||OPD care for mental illness||Treatment for alcoholism, drug or substance abuse or any addictive condition and consequences thereof. Intentional self-injury (whether arising from an attempt to commit suicide or otherwise).
Death or disablement is caused by insanity or mental, nervous, or emotional disorder.
|24 months waiting period for preexisting diseases.||—||Yes|
|6.||Digit health plus policy||—||IPD, OPD, and domiciliary care for following psychiatric disorders: F20–29, F30–39, F40–48, F99 of ICD-10. Medical expenses related to psychiatric illness will be provided if the first diagnosis and hospitalization were during the policy period as an inpatient. Hospitalization under this benefit shall be subject to prior approval except in cases of emergencies.||
This is a new area for most insurance companies, and hence some confusion is likely in the implementation.
Lack of data on the number of people with mental illness requiring inpatient care and insufficient data on the average duration of admission for a specified diagnosis could become a barrier to private insurance companies rolling out policies during the next few years.
Public sector health insurers still have mental illness under the exclusion list and are not offering coverage. For instance, the United India Insurance Company and the New India Assurance Company mention psychiatric and psychosomatic disorders in the exclusion list.22
Most policies will cover costs incurred due to hospitalization related to mental illness. OPD treatment is generally not covered unless specifically mentioned. Further, in OPD cover, claims are settled mainly by reimbursement with the cashless benefit not being given.22 Some plans may cover preexisting conditions while some may not.
A further limited number of plans may be available for severe mental illness.
Here, we present brief details on specific health insurance policies provided by private companies. Insurance policies that include cover for any mental illness are included with notable inclusions/exclusions we could find in their policy document.
CRITICAL EVALUATION OF AVAILABLE HEALTH INSURANCE POLICIES COVERING MENTAL ILLNESS
The IRDAI master circular on standardization of health insurance products (2020) states explicitly that no health insurance policy shall incorporate the following exclusions in terms and conditions of the policy: treatment of mental illness, stress, and psychological disorders and neurodegenerative disorders; behavioral and neurodevelopmental disorders, including disorders of adult personality; and disorders of speech and language, including stammering and dyslexia.27 The available health insurance policies have excluded some of these conditions in violation of the IRDAI master circular.
The MHCA 2017 definition of mental illness includes “mental conditions associated with the abuse of alcohol and drugs.”19 None of the health insurance policies follow the comprehensive MHCA definition of mental illness and exclude substance use-related disorders. IRDAI master circular on standardization of health insurance products (2020) permits exclusion of “treatment for alcoholism, drug or substance abuse or any addictive condition and consequences thereof” from health insurance coverage in violation of MHCA 2017. This exclusion is discriminatory and leaves the circular in direct contradiction of the Act, both in letter and spirit.
A key feature of MHCA 2017 was the decriminalization of suicide and presumption of severe stress in any person who attempts to commit suicide.19 The Government also has a duty to provide “care, treatment, and rehabilitation” to the person who attempted suicide.19 Unfortunately, self-inflicted injuries and suicide attempts are not covered by the available health insurance policies.
Health insurance coverage for mental illness needs to be on par with physical illness. There seems to be resistance within the health insurance sector to realize this parity in their policies. For example, available health insurance policies do not cover mental illness or have separate caps for mental illness treatment expense and limit the number of OPD visits covered or have a more extended waiting period to cover preexisting mental illness.19 Health insurance companies can be prosecuted under section 109 of MHCA 2017 for not following section 21(4) of MHCA 2017.
Though outpatient care accounts for a substantial proportion of mental health services, it is not covered by all health insurance policies.
RECENT COURT CASES REGARDING HEALTH INSURANCE POLICIES FOR PERSONS WITH MENTAL ILLNESS
A recently concluded landmark case (Shikha Nischal vs National Insurance Company Ltd (NICL) and ANR) provides much-needed direction in this area.28 In this case, the petitioner had taken a health insurance policy for a total sum of ₹3,95,000. In June 2020, the petitioner obtained inpatient care for schizoaffective disorder and incurred expenses of ₹5,54,636. The petitioner then applied for reimbursement of treatment expenses from NICL as per Clause 1.1 of the Healthcare Policy. Her claim was rejected based on the exclusion policy of the insurance stating that psychiatric disorders were excluded from the cover. She then filed a complaint before the insurance ombudsman, relying upon the provisions of MHCA, 2017. However, the insurance ombudsman observed that the petitioner’s claim would have to be settled as per the terms and conditions of the policy and rejected the petitioner’s claims. Subsequently, she filed a petition in Delhi high court that such rejection would violate MHCA 2017. During the case’s proceedings, after the hearing of March 18, 2021, the IRDAI directed the NICL to pay the petitioner’s claim. Accordingly, the maximum coverage of the healthcare policy of ₹3,95,000 (the entire sum insured) was paid to the petitioner. The Delhi high court then, in its judgment, clearly says that “mental illnesses can be treated no differently from physical illnesses. Insurance policies also cannot discriminate between these two types of illnesses. The reasons for the nondiscriminatory provisions between mental and physical illnesses are not far to seek.” Since the petitioner had to resort to litigation for the claim to be honored, the Delhi high court ordered NICL to pay another ₹25,000 as costs to the petitioner.
In another critical ongoing case (Subhash Khandelwal vs Max Bupa Health Insurance Company), the Delhi high court has questioned the IRDAI to explain the basis of approving insurance policies that exclude mental conditions from full coverage.29 The case is against Max Bupa Insurance Company, wherein the petitioner has claimed that he has been regularly paying the premium for a sum assured of ₹35 lakhs, but when claimed for the treatment and perusing the fine print, it appeared that almost all prevalent mental health conditions were capped at a sum limited to ₹50,000. The case is yet ongoing when writing this article, with the current status being the Delhi high court awaiting the response from IRDAI and Max Bupa on the basis for excluding mental illnesses from full coverage.
These cases put forth the importance of activism and self-advocacy—as well as appropriate jurisprudence—to provide the much-needed impetus to align insurance policies with the progressive requirements of MHCA 2017. The case of Shikha Nischal vs NICL reflects how the legal intervention was necessary to claim the health insurance rights for a person with mental illness. The court also observed that the IRDAI’s lack of monitoring over insurance companies was a dereliction of its statutory duty to fully supervise and ensure that all the insurance companies implemented Section 21 (4) of MHCA 2017.
ROLE OF MENTAL HEALTH PROFESSIONALS
While recent court verdicts should hopefully pressure the IRDAI and health insurance companies to correct anomalies, mental health professionals, and professional bodies need to take a more proactive role and enhance awareness among persons with mental illness on recent developments. Professional bodies can create task forces to highlight ambiguities in current health insurance policies, ensure implementation of the law, and lobby for an increase in public spending for mental health services to bridge the treatment gap. Various stakeholders, including mental health professionals, PwD, persons with mental illness, and families of persons with mental illness, need to work collectively.30
The Government of India should aim to provide universal health coverage including mental health services at par with countries, like the United Kingdom. The Government should decentralize mental health services and make community-based services available for the treatment of mental illness. The Government can also consider coming up with subsidized health insurance policies, like erstwhile “Swavlamban health insurance scheme for PwD” [as per clause 24 (3j) of the Rights of Persons with Disabilities Act, 2016]. This will cover persons disabled with mental illness. All policy measures will combat the issues related to stigma toward mental health, mental health literacy, and access to mental healthcare.
The article has summarized the status of individual health insurance policies covering mental illness in India as of June 2021. Though there is encouraging movement in this direction, a lot remains to be done. This is essential since most insurance policies cater to the population, which can afford to buy them. Thus, insurance cover provides a short-term plan for health expenditure. Comprehensive universal health coverage is the need of the hour.
Thanapal Sivakumar https://orcid.org/0000-0002-9498-9424
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