The first time 23-year-old Pronoy Mukherjee approached a psychiatrist for help, he had just begun his journey as a dental student. "It was in December 2012 that I was diagnosed with depression and bipolar disorder. My mother took me to a psychiatrist because I was suicidal. The doctor gave me a test, but the moment he saw me, he said that I was showing clear symptoms of bipolar disorder. I was given medication for that,” says Mukherjee.
Mukherjee, now practising dentistry in Mumbai, is grateful that he reached out for help at the right time. In absence of a policy, people like Mukherjee have to cash out huge sums just to be able to afford counselling. As per Mukherjee’s recollection of events, his family cashed out over Rs 50,000 for about 20 counselling sessions and treatment. “My condition is still mild. People who are admitted to rehabilitation centres have to pay about Rs 7,000 per day,” he says.
Though India passed the Mental Healthcare Act 2017, in May 2018, giving citizens like Mukherjee a right to have access to "mental healthcare", and even the Insurance Regulatory and Development Authority of India (IRDAI) even issued a circular in August asking health insurance providers to cover mental health problems as part of their policies with immediate effect, there's not a single policy in the market which covers mental healthcare. In fact, most policies continue to have clauses that exclude diseases like schizophrenia and Alzheimer’s.
According to the 2016 National Mental Health Survey (NMHS), nearly 150 million Indians are in need of mental health care services at any given point of time, while only less than 30 million seek care. The NMHS, in fact, estimates there to be an overall treatment gap of 83 percent for any mental health problem.
It further found that major depressive disorders and anxiety disorders had a treatment gap of 85.2 percent and 84.0 percent respectively. Overall, only about 1 in 10 people with mental health disorders are thought to receive evidence-based treatments in India. According to WHO, India may as well be eyeing a national crisis in mental healthcare with 20 percent of the population facing mental healthcare problem by 2020.
Then why the relaxed approach to providing mental healthcare in India?
Insurers confused about what constitutes mental illness
One of the reasons for the delay is the definition of the term “mental illness” in the Mental Healthcare Act 2017.
Mayank Bathwal, chief executive officer at Aditya Birla Health Insurance Company (ABHIC) says that it is easier to chalk out policies for in-patient facilities (which include hospitalisation) because of the already available data and existing clarity on benefits for customers, but in mental health care, there is work that needs to be done in terms of understanding the range of issues or the benefits that insurers need to provide.
“We are now reviewing the process. Mental health is a fairly vast area,” he says.
Bathwal informs that ABHIC is looking at how to provide "mental healthcare" benefits and is in touch with the IRDAI to seek clarification wherever required. "We will offer these benefits at the right time,” he says.
According to Bathwal, some of ABHIC’s group offerings already provide customers optional benefits which consider the prevalence of mental health conditions.
“Our sensible belief is that ultimately a lot of lifestyle chronic disease conditions like diabetes, asthma, hypertension, cholesterol are somehow related to stress or mental health. We also need to be very clear about what is mental health. Our products are already covering some of these lifestyle conditions, and when our health coaches have interactions with our customers, the top areas they talk about is how to deal with stress, etc. So, in some sense, we’re already providing some of these benefits and we’re doing some of these interactions with our existing customers. How do you take it ahead in terms of OPD expenses or hospitalisation expenses are areas that will evolve.”
Bathwal believes that addressing mental health issues will, in the long run, bring down the number of cases of physical illnesses and the overall healthcare cost. However, he feels that more dialogue between insurers and the IRDAI will be helpful. “There no reason why the industry cannot provide benefits,” he says.
ICICI Lombard, on the other hand, is ready to cover mental illness according to the IRDAI's direction. In an email response, Sanjay Datta, chief – underwriting, claims, reinsurance and actuarial, ICICI Lombard, reveals that his company “shall abide” by the IRDAI circular. “Our existing policy will cover mental illness in the same manner as physical illness as per policy terms and conditions,” he says.
On the process to avail benefits from products for mental health, Datta says, “Just like customers who disclose any physical illness are evaluated to determine whether a policy can be issued, customers who disclose any mental illness will also be evaluated on appropriate parameters. On acceptance of their proposal, they shall be offered our retail health indemnity products.”
He agrees that the Act and the IRDAI circular will ensure increased awareness about mental illnesses and reduce the stigma associated with it. However, as insurers, the company needs to "analyse the data, to revise the premiums if need be, introduce some waiting period to avoid cases of anti-selection, etc".
Drawing new policies is a long process
According to Vaidyanathan Ramani, product and innovation head at Policybazaar.com, before the IRDAI circular, almost 99 percent of the retail health products listed on the website had an exclusion on mental illnesses. Exclusions are the cases for which an insurance company does not provide coverage.
“After the IRDAI circular, it (the provision on insurance) was effective immediately. While the policies, document, terms and conditions have not changed yet — because they have to be filed with the regulator — the circular meant that insurers, despite not having made changes to terms and conditions, will have to start offering those benefits. All these insurers have to go back and refile their terms and conditions because the document which is currently written for most of them will have a clause which says that anything to do with schizophrenia, Alzheimer’s are excluded. Technically, they’ll have to erase this sentence. That has not happened because it’s a long drawn process. Most insurers are in that process,” he says.
While the Act implies that everybody is deemed covered from mental health problems, how the insurers cover their customers also depends on how the companies interpret the three lines of IRDAI in the circular, Ramani says.
“Different insurers can interpret it in different ways. For example, today there are health insurance policies which cover you typically only if you’ve been admitted to hospital for more than 24 hours. If you have not, then there are special lists under which the coverage is allowed, like day-care procedures. One quick interpretation of the IRDAI circular is that an insurer will also cover mental health insurance the same way. In the flux period before each insurer has gone ahead and refiled their terms and conditions in what they will cover, it will be difficult to guess what is covered because they cannot tell anything to the public before the IRDAI allows them,” he says.
Ramani’s understanding is that there is an informal committee constituted between the insurance companies which is actually looking into defining mental illness and standardising the procedures.
"They (insurers) are in the process of doing this, post which the insurer will go ahead and file this and get their documents ready. In the intermittent period, one has to go with what could be an interpretation of the law with their respective insurer. For the public, the best way to know is to call your insurer and ask for clarification on what is covered," he says.
While insurers are themselves unsure by when the process will be complete, Ramani thinks that it should be done by the end of the current financial year.
An important thing to note is that the development will affect the insurance premium for individuals. “It depends on where each insurer draws the line. For anything that is an extra cover, the insurer and the IRDAI both have to prove that there is enough premium in the provision to cover that additional event, which means every product will have a northward direction,” Ramani says.
‘Act enough for quality assistance’
Pune-based psychiatrist Soumitra Pathare, who was also involved in the drafting process of the Bill, believes that insurers don’t need to actually struggle with the new rules. “They (insurers) only need to remove the exclusion of mental illness in their health policies. Parity is all they need to provide. They do not need to provide any special policies for mental illness,” he says.
Pathare further holds the view that the present provisions in the Act are sufficient for patients to get quality assistance.
According to the Act, every state must ensure that quality assistance is provided. Pathare strongly rejects that seeking help for mental conditions is seen as something for the elite. “Go to any public mental health service, and you will see two things — lots of people taking help, seeing a psychiatrist/psychologist and most, if not nearly all of them, come from lower socio-economic class,” he says.
However, the social challenges still exist, he says, adding, “There are more conversations about it (mental health) happening in public spaces. Society seems more accepting about persons with mental health problems. But stigma and discrimination remain as before.”
Need for a community-based approach
The Mental Healthcare Act describes “mental illness” as “a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs, but does not include mental retardation which is a condition of arrested or incomplete development of (the) mind of a person, specially characterised by sub normality of intelligence.”
Section 18(1) of the Act says that every insurer should make provisions for medical insurance for the treatment of mental illness on the same basis as is available for treatment of physical illnesses.
The Act largely places the onus on the Central and state governments to work on the deficit of mental health care institutions. “The appropriate government shall make sufficient provision as may be necessary, for a range of services required by persons with mental illness,” says Section 18(3) of the Act.
Nirmala Srinivasan, disability rights activist and Ashoka fellow, disagrees that laws can entirely solve the problem. “Making mental health care a right of every citizen is a great step and a leap forward. But it remains an issue. Law cannot take care of everything.
Srinivasan says that one of the main problems that a person with mental illness (PMI) faces is access to medical intervention or an expert. As seen across the world, a PMI is often expected to travel 30 kilometres to meet an expert.
"There is no assurance that the person in need of treatment or a person who has to do follow up treatment, will seek help by travelling those 30 kilometres,” she says, adding, “There is a lot of denial and resistance from the patient. This becomes the roadblock in the access to treatment. Even if then treatment is available, seeking and accepting it is a big challenge for the family. At least some sort of initial hand holding, pampering, and care — more than what the act says — can come only in a programme.”
Addressing the issue, Srinivasan says, “My concern is when we know these things have been there, how do we make the Act relate to this national crisis? We are in the grip of a mental health emergency. I have still not read any document that is linked to how do we plug this gap, and how do we catch hold of the people who are not able to exercise their right to access treatment.”
In 2015, Srinivasan founded Families Alliance on Mental Illness National Network, a family advocacy group to identify gaps in the existing scenario.
“From our forum, I've initiated a campaign for what is known as assisted family care (AFC). Official statistics say that 70 percent of PMIs in India live with their families. AFC’s idea is to make help available on the spot, by providing a routine programme (a phone call or a routine visit), medication, or counselling. China took about a decade to reduce the treatment gap. Let us at least pilot it here. This way, we can ensure that even PMIs can exercise their right to access care,” she says.
As insurers work out a way to to cover mental illnesses, Srinivasan advises people to wait till there is more clarity regarding policies. “Until then, one thing they (families of PMIs) must know is that mental illness has now come out of the permanent exclusion category, which is a historic thing. Secondly, they should have the IRDAI letter with them, and preferably they should read the legislation. The whole legislation is a game changer for everybody. It assures a better quality of life, provided we want it,” she says.
Srinivasan adds, "When we talk about family care, the fact remains that family is the largest model of care. Therefore, it should be given more official recognition, and more programmes should be investing in family care rather than opening community centres. These centres may not get sufficient staff, have undertraining issues, etc. Instead of that, training the families, and empowering them would be a better pathway to get this right-based legislation rolled out for the next five to ten years.”
One of the five “grand challenges” noted by the 2016 NMHS was providing effective and affordable community-based care and rehabilitation. The latest legislation for mental healthcare, enforced in May, addressed the issue of high treatment costs for medical care.
A significant feature of the Mental Healthcare Act, 2017, is that it is the first law in India which has mandated universal mental healthcare for all citizens.
But to make it a reality, health insurers and the insurance regulatory body, Insurance Regulatory and Development Authority of India (IRDAI), have a lot of ground to cover, including deciding on standard of procedures to be followed, terms and conditions for insurance policies, evaluation parameters to be used to screen patients, and the cost of premium at which mental healthcare could be 'covered'.
Updated Date: Oct 10, 2018 14:28 PM