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Understanding mental illness: When insurance and psychiatry meet, what language do they speak?

Editor's note: What does it mean to be ‘mentally ill’? In this weekly column, Sneha Rajaram writes about navigating through a ‘mentally ill’ life — encompassing aspects that are both everyday (medications, rights) and contemplative (the universality of suffering).

Over the last few years, a new opportunity for victimhood has presented itself in my life, overlapping with actual victimisation somewhat – my search for purely medical insurance, not covering psychiatry or death. In 2015 I was asked by an insurance company (in this case, a government subsidiary) to get a letter from my psychiatrist, although their policy didn’t cover psychiatry or suicide. My psychiatrist obliged, using words like “currently stable” and “attending follow-up sessions regularly”, but I was rejected nevertheless. This year, I finally mustered the courage to try again with another (private) company. This time I was rejected within an hour of payment and my money refunded.

The customer care executive called me and said their doctor had rejected my application on the grounds of the disease I’d mentioned: “bipolar disorder”. This very obvious discrimination resulted in the exploration of a world new to me.

I was merely searching for an insurer to cover possibilities of physical disease (say, cancer) or accident. Not bipolar. (As one insurance agent paraphrased this back to me: “Is cheez ka cover nahi chaahiye na?”) So the idea of my mental illness being covered (albeit after a reasonable cooling-off period) seemed far-fetched.

 Understanding mental illness: When insurance and psychiatry meet, what language do they speak?

The Mental Healthcare Act of 2017, states that “any other health services provided to persons with physical illness shall be provided in same manner, extent and quality to persons with mental illness”. Illustration courtesy Satwik Gade

But Section 21 of the progressive Mental Healthcare Act of 2017, titled Right to Equality and Non-Discrimination, states that “any other health services provided to persons with physical illness shall be provided in same manner, extent and quality to persons with mental illness,” and “Every insurer shall make provision for medical insurance for treatment of mental illness on the same basis as is available for treatment of physical illness.” A year after the Act was passed, the Insurance Regulatory and Development Authority of India issued a directive: “All insurance companies are hereby directed to comply with the aforesaid provisions of the Mental Healthcare Act, 2017 with immediate effect.” This resulted in a bunch of news stories that interviewed the mentally ill as well as insurers and explored what the implications of this would be. A representative of an online insurance agent was quoted as saying that "Insurers are to start covering mental illness from the day the regulation was issued which is 16 August, 2018 and the mental illness will be covered in the existing plans to the extent specified by the National Mental Healthcare Act, 2017. With more coverage, an increment in premium is expected in six to ten months as companies go for revision in the policies.” However, as far as I know, no policies have been revised to include mental illness yet.

I know this because I’ve turned to insurance agents now in my search for a policy to cover physical disease and accidents. I expected some companies to simply demand a higher premium. Instead, I was directed to all of two existing policies that wouldn’t cover pre-existing diseases and therefore presumably felt safe from my bipolar disorder. The bipolar, I was told, would be treated as a “permanent exclusion” – ominous-sounding jargon but not my primary concern at the moment. When I rejected one of these policies because that particular company had filed for insolvency, I was subjected to some rather paternalistic and unpleasant rhetoric from the agent, who (perhaps reasonably) expected me to be grateful that anyone would underwrite me at all. Insurance companies, it seems, can reject me for supposed financial unviability, but I cannot do the same to them.

From a certain viewpoint, it is in fact reasonable for insurance companies to reject what, even in 21st-century actuarial exams, are called “bad lives” (or more usually “substandard lives”).

They think mental illness can lead to physical illness or accident (on what basis, I don’t know – aren’t actuarial studies called “actuarial science”?). Viewed as a purely capitalist enterprise, insurance companies can be expected to only seek profit. However, insurance is regulated and has been conflated with social service under socialism, perhaps rightly so in the case of nationalised insurance companies. The result is insurance agents who tell you that insurance is one of the most desirable factors in social and personal harmony and that in the ultimate utopia, everyone is covered (at different premiums, of course).

So we end up with insurance companies that sound benevolent but practice discrimination, either by rejecting policies or charging higher premiums. Discrimination is nothing new in the history of insurance, though: In the 19th century, Indians were charged 10 percent more than the premium for Europeans. I don’t know anything about caste and gender discrimination in the history of insurance, but I’m willing to bet it exists. The very terms “good” and “bad” lives, “standard” and “substandard” lives, make it seem very likely – because who decides these things and on what basis?

I should be cautious about politicising my own health insurance, since a more pragmatic, private and persistent approach is likely to get me a longer, healthier, more comfortable life. What of people who can’t afford insurance at all though? Or people who can’t afford higher premiums meant for the mentally ill? Or those who have already been hospitalised multiple times for mental illness? Or those who would be rejected not on the basis of mental illness, but of income, gender, caste, physical illness? Or those who need to cover outpatient psychiatric expenses?

I’m hardly familiar with the politics of insurance discrimination. But I do know that in modern life, antibiotics, physical comfort, medical treatment and long lives are taken for granted by the privileged. In such a world, sorting and quantifying people and their bodies ensues. It’s not hard to imagine which people at the margins of society are treated as “permanent exclusions”. This is done on the basis of actuarial science, a commonly respected discipline, which works on assessing and regulating risk in insurance. A useful way to understand this kind of risk regulation is through the scholar Michel Foucault’s concept of “biopower”, which he defined as "an explosion of numerous and diverse techniques for achieving the subjugation of bodies and the control of populations", of which insurance is one such.

In this context, the word “functionality”, used by psychiatrists so much, seems less like a benevolent concern for our ability to take care of ourselves and more like a calculated assessment of our tangible contribution to society based on economic and other visible criteria. After all, psychiatry’s terminology wasn’t born in a vacuum. After all, the insurance company did require a letter from my psychiatrist affirming my stability. The joke, however, is on psychiatry, because in my case the letter didn’t cut it. That means that the concept of “functionality” may serve psychiatry well, but it serves neither the patient nor the world as much.

Read more from this series

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Updated Date: Apr 11, 2019 09:32:06 IST

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