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Journalism of Courage
Dr Shailesh Jha, a psychiatrist at Delhi’s Indraprastha Apollo Hospital, has his hands full. Every day, he sees around 25 patients, most of whom are grappling with common mental health challenges like depression, anxiety and Obsessive Compulsive Disorder (OCD). All of them are covered by health insurance policies but, to his surprise, each falls short in covering crucial expenses associated with treatment that can bring them back from the precipice.
Despite India’s insurance regulator mandating mental health cover since 2018, the practical coverage lags much behind in targets, leaving patients unable to continue therapies that would get them out of the trough. Things haven’t changed despite the regulator reiterating the directives in 2022. Consider the case of a 32-year-old patient whom Dr Jha found to be suicidal and recommended be kept under observation for a few days. Confident that her family’s insurance coverage would easily tackle the expenses, the convoluted clauses and time-consuming system left the patient unable to leverage it. “I kept receiving calls from representatives of the insurance providers asking me to justify the reason for suggesting hospital admission,” says Dr Jha, who has since started warning his patients that insurance providers may not help when needed. While self-harm, attempted suicide and suicide are listed as exclusions in almost all health insurance policies, experts say getting paid for claims relating to hospitalisation due to mental illnesses is difficult. Not only that, it is extremely difficult for people with a pre-existing mental illness to get a policy. “Although the Mental Healthcare Act, 2017, ensures that coverage cannot be denied, many patients want to keep psychiatrist consultation off the book. They are scared that their claim for other illnesses, say a heart attack, would be denied if their mental health issue is put on record,” says Dr Jha.
“Most mental disorders are life-long and a person may have more than one condition. Insurance policies in India cover acute episodes requiring hospitalisation but what is needed is support for long-term therapy sessions or rehabilitation facilities that may actually pull you off the edge,” says Madhurima Ghosh, former research fellow with Gokhale Institute of Politics and Economics and a cost evaluation coordinator at Sangath (an organisation that’s working to make mental healthcare accessible and affordable). Her yet-to-be-published survey of 100 mental health providers across four cities shows a patient could end up shelling out anywhere between Rs 60,000 and Rs 80,000 for outpatient treatment. Imagine the out-of-pocket expense for patients as an hour-long therapy session can cost anywhere between Rs 1,000 and Rs 5,000. “Most patients need long-term treatment, including psychological and pharmacological treatment, but get no help at this stage,” adds Dr Jha.
All five insurance policies — from three private and two government providers —evaluated by The Indian Express exclude the treatment of alcoholism, substance use disorders, self-harm and suicide. The policies exclude crucial rehabilitation care that’s defined as: “Custodial care either at home or in a nursing facility for personal care such as help with activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled people.” Yet rehabilitation centre-based care becomes important because of sustained individual and group therapy sessions. For the record, alcohol, substance use disorders and schizophrenia account for a significant burden of mental health problems, with the National Mental Health Survey pegging their prevalence at about five per cent.
None of the policies provides any outpatient care, which involves hours of counselling and medication. One of the government policies specifically excludes “psychological counselling, cognitive/ family/ group/ behaviour/ palliative therapy or other kinds of psychotherapy.” However, it does mention that treatment for depression and schizophrenia will be covered after a waiting period of two years, overlooking the cost of delayed access to insurance relief. The other policies do not specifically mention mental illnesses but cover all pre-existing conditions after 36 to 48 months.
“No policy covers talk therapy,” says an agent from Policy Bazar on being asked to recommend a policy for a 30-year-old, physically healthy woman with anxiety and depression. A similar conversation with an agent from Ditto Insurance resulted in a non-committal response: “You might get coverage for hospitalisation due to depression and other mental health conditions after a certain number of years. But, in most cases, it is likely to be a permanent exclusion in the policy.” While add-ons exist for outpatient coverage that can be purchased along with general health insurance, it is not beneficial, says portfolio manager Gaurav Shrivastav. “There is a restriction on the percentage of payments with these add-ons. If you need long-term care, the payments do not justify the extra premium,” he adds.
Last year, at least 29 companies floated policies specifically for people living with disabilities, HIV and mental illnesses, according to an affidavit filed by the Insurance Regulatory and Development Authority of India (IRDAI). An analysis of one such specialised policy offered by one of the government providers shows that it does not cover outpatient services such as therapy. In fact, for its daycare services, it specifically mentions it has to be “under General or Local Anaesthesia.” Just like other policies, it does not offer treatment for alcoholism and other substance use disorders, suicide, hormone replacement therapy or gender reassignment surgery. However, it includes a co-pay of 20 per cent on all claims.
Living with bipolar disorder, mental health activist and co-founder of Mental Health Support Foundation Vijay Nallawala says that he has managed to get coverage at a substantial premium but the policy has a sub-limit of 25 per cent of the sum insured for his condition. “Equal coverage for mental health remains only on paper. The reality is that only a fourth of the people with mental health issues manage to get covered and even then we keep hearing of claims getting rejected,” he says.
One of the biggest challenges with mental health disorders is that they are not quantifiable in the same way as a chronic physical ailment like diabetes or hypertension. There aren’t any tests to assess the level of say anxiety or depression. Therefore, insurance companies require a certificate from a doctor on their panel to provide coverage for a pre-existing condition. “As there is no test for say anxiety or depression, the doctor certifies what is the ‘level’ of the condition. If it is certified as say 20 or 30 per cent, then a person is likely to get immediate cover. If it is 40 per cent to 50 per cent, there is likely to be a waiting period of a few years,” says Shrivastav.
