Should you count on health insurance for mental illness treatment? Not blindly

Should you count on health insurance for mental illness treatment? Not blindly

While insurers now see the physical and mental diseases from the same prism, the treatment of former is quite different from the latter

Mental health insurance policies Mental health insurance policies

Mental illness hardly got the attention it deserved in the past. However, the grave consequences of ignoring it are bringing a change in the attitude. Early identification and timely treatment can surely prevent untoward incidents. As awareness around mental health is growing, so is the institutional support. Complying with Mental Health Act of 2017, health insurers have included mental illness cover as a standard part of health insurance policies. However, can you depend on it for the full treatment? Not really.

While insurers now see the physical and mental diseases from the same prism, the treatment of former is quite different from the latter. And health policies are not constructed in a way that mental health patients can take much benefit out of it.

OPD is key

Patients suffering from mental diseases do not require hospitalisation in the initial stage. Outpatient counseling sessions with psychiatrists is how treatment begins. However, 95-98 per cent insurance policies in India do not cover OPD expenses. They only provide inpatient (IPD) benefits. Gradually, some insurance policies have started including OPD component, but of a small amount - negligible to what a couple of counseling sessions may cost a patient. "Some insurers do have OPD component in health policies, but it may not be more than Rs 10,000-20,000 for a basic sum insured of Rs 10-15 lakh," says Naval Goel, CEO,

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OPD coverage in health insurance is a tricky issue. There are high chances of frauds and leakages. "We need automation in processing OPD claims too, because manual processing for frequent and smaller amount of claims will not be viable for insurance companies," says Dr. Bhabatosh Mishra, Director Underwriting, Products & Claims at Max Bupa Health Insurance.

Insurers offering OPD cover

Needless to say, if you want your health policy to cover mental illnesses, you must go for the ones with the OPD component. "A person suffering from mental health should ask for a policy that covers all daycare procedures. The regulation governing mental health will not help unless public knows what type of policies they should purchase in this scenario," says S. Prakash. Managing Director, Star Health and Allied Insurance.

Star Health has a separate OPD cover - Star Outpatient Care Insurance Policy - that you can buy as an add-on to your health policy and pay additional premium for it. The plan offers four sum insured options - Rs 25,000, Rs 50,000, Rs 75,000, and Rs 1,00,000. Other policies of the insurer also cover outpatient consultation, daycare procedures and pharmacy etc, if those have OPD component.

ICICI Lombard has policies such as Health Protect Plus, Health Smart and Health Smart Plus that come with the OPD component in it. Max Bupa's Health Premia policy has the OPD component. The crux is to enquire beforehand about the OPD coverage in health policies.

Limited in-patient coverage

Hospitalisation in mental diseases come much later. And even if it occurs, it's difficult to measure for how long a patient has to stay in the hospital or what treatment he may require. "The decision to admit or discharge patients is not as standard or time-bound (when it comes to mental diseases) as it is for malaria, dengue or surgery for gall bladder and appendix etc," says Mishra of Max Bupa.

Secondly, some may have to get admitted to medical care centres which are not hospitals by definition, hence not covered under insurance policies. "A segment of mental health diseases is about habit-forming drugs etc. If patients are addicted to a drug, say cocaine, they get admitted to de-addiction centres. These are medical health providers not hospitals per se. Insurance products have exclusions with regards to de-addiction centres."

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A collective thinking among all stakeholders and subsequent guidelines are required to iron out such issues. "These issues are not unidimensional. It'll take time to think through the challenges. The extent of coverage anyway evolves with the passage of time," Mishra adds.

Experience so far

Star Health says it has received thousands of claims related to mental health in last one year. "What we have observed is primary disease could be different, but doctors may find out later that mental disease is the key reason why they have physical ailment. So, people might get admitted for undiagnosed diabetes, headache or abdominal pain, but upon admission and investigation, the doctor may diagnose that they are suffering from mental disease," says Dr. Prakash of Star Health.

Max Bupa and ICICI Lombard may have received negligible claims related to mental illness, but enquiries for counseling sessions have gone up. "Mental health coverage under insurance is at a nascent change. We do not want to put cart before the horses, but we are working on taking initiatives to give best coverage to mental care. We have started offering tele-consultation to policyholders. Lot of enquiries we receive for counselling with psychiatrists," says Sanjay Datta, Chief - Underwriting, Claims & Reinsurance with ICICI Lombard.

Max Bupa says the taboo around talking about mental health in India hinders them collect data to construct suitable mental health insurance plans. "Global insurers like Bupa cover all forms of mental illnesses and have comprehensive covers including long term mental health care. In India, it has always been a challenge to trace individuals living with mental health disorders. Hence it becomes tedious to design covers for mental health without sufficient data, which still remains a challenge for us," says Mishra.

What you should know

As explained above, OPD coverage is a must if you want yourself covered for mental diseases. If there is known family history of such diseases you should be proactive at adding the OPD coverage. If you are already suffering from a mental disease, and you declare it while buying the policy as a pre-existing disease, its coverage will start only after a waiting period of up to four years. You should enquire about it before buying the policy.

Also note that it is not that insurance companies have to accept your policy proposal when you approach them. Anxiety, depression or hypertension are fine, but if a patient is suffering from severe bipolar disorder, she may not get a policy.

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