In a developing country like India private out-of-pocket expenditure rules the cost of financing of health care. According to National Health Accounts (2016), 64.2% of the total health expenditure is out-of-pocket payments. Out-of-pocket expenditure mainly consists of direct costs such as doctor’s consultation fee, medicine charges, laboratory, and other diagnostic charges.
MENTAL HEALTHCARE ACT 2017
The new act defines “mental illness” as a “substantial disorder of thought, mood, perception, orientation, or memory that grossly impairs judgment or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs.” The existing Mental Health Act 1987 was revoked for not recognizing the rights of mentally ill persons. The Mental Healthcare Act 2017 treats mental disorders at par with physical disorders. There are various provisions mentioned in the new Act including decriminalization of attempted suicides and certain changes in the process for admission, treatment, and discharge of mentally ill persons. This act also includes financial punishment in case of violation of the act. The Insurance Regulatory and Development Authority of India (IRDAI) in 2018 had directed the Indian insurance companies to cover mental disorders as per the Mental Health Act, 2017.
A Public Interest Litigation filed in the Supreme Court by advocate Gaurav Kumar Bansal pointed out that the companies were violating the provision of the 2017 Act. A three-judge bench headed by Justice R F Nariman called for a reply from both the government and IRDAI. The IRDAI had instructed all insurance companies to introduce policies for mental illness by October 2020.
The nations with high human development indices have already formulated a robust mental health care system and thus can give us a clue regarding how to go about it.
Medicaid and Medicare are federal health insurance plans. Americans with low income irrespective of their age are eligible for Medicaid. Mental health services in Medicaid generally cover inpatient and partial hospitalization, residential care, outpatient mental health services, nonemergency transportation, case management, peer support services, psychiatric rehabilitation, crisis for children intervention, prescription drugs, long-term care, early periodic screening, diagnosis, and treatment services. Medicaid plans may also cover additional services such as psychosocial rehabilitative services, In-home and family support services, Assertive Community Treatment (ACT), and Multisystemic Therapy.
Children’s Health Insurance Program (CHIP) is a state and federal health insurance scheme for children under the age of 19 years and whose families earn more than to qualify for Medicaid but not enough to buy private insurance. CHIP covers the following mental health benefits-inpatient hospitalization, outpatient mental health treatment, emergency care, and prescription drugs.
TRICARE and VA Health Care are federally run health insurance schemes only for people who served the military. Inpatient hospitalization for 30–45 days per admission or year, partial hospitalization for 60 days per year, outpatient mental health services, psychiatric residential treatment (children and youth), emergency care, and prescription drugs are covered under these schemes.
The National Health System (NHS) is the United Kingdom’s (UK’s) publicly funded scheme for all the residents of the UK. Mental health services are free under the NHS but in some cases reference from general practitioner is required. Services that are included are psychological therapy and counseling services; drug and alcohol services; children’s mental health services and eating disorder services. It includes all aspects of mental health care-promotion, diagnosis, assessment, rehabilitation and care, treatment, and support to caregivers. Around 10% of the country’s GDP is spent on healthcare. Only around 10.5% of UK residents opt for private health insurance. In the case of private insurance, “mental health” for most insurers will include all aspects such as stress, postnatal depression, ADHD, eating disorders, addictions, ME, fatigue, as well as depression and anxiety. Individuals will typically be asked to provide their diagnosis, symptoms, and treatment.
Thus, it is evident that different industrialized nations have already taken care of the problem of mental health with utmost care. Either Government or private insurers have formulated several insurance products to ease the burden of payment for chronic illnesses. Furthermore, outpatient services and prescription drugs have come under their gamut which is a commendable step to manage mental illness.
PRESENT SCENARIO IN INDIA-AYUSHMAN BHARAT
Ayushman Bharat, the flagship program of the Government of India, was designed to meet the Sustainable Development Goal 3 and achieve Universal Health Coverage. Ayushman Bharat adopts a two-fold approach namely Health and Wellness Centres and Pradhan Mantri Jan Arogya Yojana (PM-JAY). Ayushman Bharat PM-JAY is the world’s largest health insurance scheme providing health coverage of INR 5 lakhs per family per year. It covers the bottom 40% of the Indian population for secondary and tertiary care hospitalization which is cashless coverage in the empaneled hospitals.
Ayushman Bharat PM-JAY has coverage for mental disorders. Although it was launched with 17 packages initially, it was reduced to 10 in December 2019. A package includes all treatment costs including pre- and post-hospitalization costs. PM-JAY has fixed procedure price of INR 1500 for the following disorders: Mental retardation, mental disorders-organic, including symptomatic, schizophrenia, schizotypal, and delusional disorders, neurotic, stress-related and somatoform disorders, mood (affective) disorders, behavioral syndromes associated with physiological disturbances and physical factors, mental and behavioral disorders due to psychoactive substance use. The charges for Electroconvulsive Therapy (ECT) and Transcranial Magnetic Stimulation (TMS) are INR 3000 and INR 1000 per session, respectively. The required investigations before ECT and TMS (cognitive tests, complete hemogram, liver function test, renal function test, serum electrolytes, electrocardiogram, computed tomography/magnetic resonance imaging of the brain, electroencephalogram, thyroid function test, The venereal disease research laboratory, HIV Test, Vitamin B12 levels, folate levels, lipid profile, and homocysteine level) are covered under a package of INR 10000.
Arogya Karnataka is a health insurance scheme only for the residents of Karnataka which includes mental illness. It was initiated by the Government of Karnataka in March 2018, for below poverty line patients and as a copayment method for above poverty line patients. There are different packages available for mental illnesses which include mental and behavioral disorders due to psychoactive substance abuse, schizophrenia and delusional disorders, mood disorders, stress-related disorders, and mental retardation.
PUBLIC AND PRIVATE INSURANCE COMPANIES IN INDIA
To the end of 2019, there was no effort from private insurers to introduce coverage for mental illness; surprisingly, we observed the COVID-19 lockdown from March 2020, changed the scenario. Public insurance companies National Insurance Company Limited and Oriental Insurance Company Limited have included mental illness in their policy which will indemnify the hospital or the insurer only in case of hospitalization. It is clearly mentioned in their policy brochure that any kind of counseling, cognitive behavioral therapy, or psychotherapy which does not require hospitalization is excluded from their policy. Alzheimer’s disease, dementia in Alzheimer’s disease, and Parkinson’s disease are permanently excluded if they exist at the time of taking policy in the case of National Insurance Company Limited. However, even on an extensive search on the insurer’s website, specific mental illness plans were missing.
As of October 2021, insurance plans for mental health treatment are being provided by HDFC ERGO and Aditya Birla Health Insurance is offering counseling and consultation costs apart from hospital expenses. In the case of ManipalCigna Health Insurance, mental illnesses are covered under comprehensive indemnity plan which offers insurance only in case of hospitalization. Max Bupa Health insurance company in their Health Recharge Insurance plan has coverage for mental disorder treatment up to the sum insured and sub-limit applicable in some cases.
LIMITATIONS OF INDIAN MENTAL HEALTH INSURANCE
Insurers in India are more accustomed to creating products which cover episodes of illness and that too involving hospitalization. However, some mental health conditions are treated on an outpatient basis and some require hospitalization for a few weeks to a few months. Even after discharge patients need to be on medication for a long time which is an economic burden to the families. In some of the cases of mental disorders, there is more than one diagnosis. More clarity is required on the waiting period after which specific mental illnesses are covered.
Treatment of mental disorders not only requires medications but also rehabilitation, psychotherapy, and counseling which again can cause financial crises for the families. The insurance companies have a predetermined premium loading for preexisting medical conditions. In case of mental illness applying the same will be challenging. In some illnesses such as recurrent depression, bipolar disorder, and schizophrenia, the disease lasts lifelong necessitating a chronic expenditure. There are many court cases against insurance companies for rejecting the claims of mental illness. A petition was filed against Max Bupa for discrimination of insurance between physical illness and mental illness on April 2021. The petitioner had paid the premium timely for a sum insured of Rs. 35 lakhs. However, at the time of claiming insurance for mental illness, he was informed that there is capping up to Rs. 50,000 in case of mental illness with a few other conditions, which is a violation of the MHCA, 2017.
MHCA, 2017, is a welcome step toward the changing face of health insurance and giving equal importance to physical and mental illness. Still, there is a huge gap between the developed nations and the developing nations in the case of mental health insurance. There are a lot of factors which hinder the development of the mental health insurance industry in India. India’s population in 2020 is more than 1 billion and more than 150 million people require mental health services. Pre-COVID-19 situation was already grim in India and this pandemic has posed a serious threat to mental health. Hence, COVID-19 has offered an opportunity to press for proper mental health coverage by insurance companies in India which will go a long way in ensuring proper care and treatment of persons with mental illness.
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Conflicts of interest
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