Mental Illness Coverage In Health Insurance
  • Benefits of Mental Illness Coverage?
  • Best Plans For Mental Illness Coverage
  • How To Check About Mental Illness Coverage In Your Plan?
Mental Illness Coverage
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Mental Illness Coverage

Certainly, there has been enough concentration laid on the rapidly increasing physical health complications in the country due to several reasons such as environmental pollution, sedentary lifestyle, etc and the need to protect people with a strong insurance system that provides sufficient financial protection against various kinds of illnesses.

On the contrary, there is hardly any conversation about the increasing cases of mental illness amongst the masses. If numbers are to be believed then, according to WHO studies, over 90 million Indians, or 7.5 percent of the country's population of 1.3 billion, suffers from some form of mental disorder. Even a 2019 study by a British charity, Mental Health Research UK, found that 42.5 percent of the employees in India's corporate sector suffer from depression or an anxiety disorder i.e. almost every second employee. According to the National Mental Health Survey 2016, about 130 million people require mental health services.

More shockingly, an online doctor consultation website revealed a record growth in the demand for mental illness treatment post the hit of the pandemic. The online queries for psychiatry grew 50 per cent in the first two weeks of the lockdown in 2020, with most queries coming from the age group of 21-30 years. Online consultations for mental health queries grew 180 per cent into the six months of the COVID-19 pandemic.

The above given numbers as well as the excessive number of people being vocal about their psychiatric illnesses have demonstrated an urgent need of a mental care system in India to offer a proper infrastructure as well as facilities to the patients battling with such challenges including 'Insurance'.

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Mental Health Insurance

Mental Health Insurance

New Scenario Of Mental Illness Coverage in Health Insurance

The Mental Healthcare Act, 2017,implemented in 2018, directs every insurer offering health insurance products to cater to policyholders with mental illnesses the same way they cater to physical illnesses or injuries.

The Mental Healthcare Act, 2017, implemented in 2018, directs every insurer offering health insurance products to cater to policyholders with mental illnesses the same way they cater to physical illnesses or injuries. In addition to this, the Insurance Regulatory and Development Authority of India has mandated all the insurance providers to curate specific mental illness dedicated plans for the people suffering from various mental health issues.

One notable alteration of the act is that patients now have the freedom to choose from a range of mental healthcare facilities The law ensures several fundamental rights, including social inclusion, privacy, access to health information, protection from cruel or inhumane treatment, and the prohibition of discrimination. Even underprivileged and homeless individuals with mental illnesses are eligible for free mental health therapy, regardless of their economic status.

Specifications Needed For Mental Health Insurance

It is important to note that mental health insurance aims to provide coverage for future treatment and support, regardless of past conditions. Here are a few eligibility criteria:

  • Age
    Most insurance policies have a minimum and maximum age limit for enrollment. Typically, individuals above 18 years of age can apply for mental health insurance coverage.
  • Pre-existing Mental Health Conditions
    Many insurance companies may assess the presence of pre-existing mental health conditions before providing coverage. Pre-existing condition exclusions or waiting periods may apply to some insurance.
  • Medical History
    Insurers may consider an individual's medical history, including any past or current mental health issues, treatments, or hospitalizations.
  • Premium Payment
    Eligibility for mental health insurance is also contingent on paying the required premiums. Premiums are typically based on factors such as age, medical history, coverage limits, and selected policy features.
  • Insurer's Policy Guidelines
    Each insurance provider may have its own specific guidelines and requirements for mental health insurance eligibility.

List of Illnesses Covered Under Mental Illness Insurance

The specific mental illnesses covered by mental health insurance can vary depending on the insurance policy and provider. However, here are some commonly covered mental illnesses under mental health insurance:

  • Major Depressive Disorder (Depression)
  • Generalized Anxiety Disorder
  • Bipolar Disorder
  • Schizophrenia
  • Obsessive-Compulsive Disorder (OCD)
  • Post-Traumatic Stress Disorder (PTSD)
  • Panic Disorder
  • Social Anxiety Disorder
  • Specific Phobias
  • Eating Disorders (such as Bulimia)
  • Substance Use Disorders (related to alcohol or drug abuse)
  • Attention-Deficit/Hyperactivity Disorder (ADHD)
  • Autism Spectrum Disorders
  • Personality Disorders
  • Dissociative Disorders
  • Sleep Disorders (such as Insomnia)
  • Adjustment Disorders
  • Somatoform Disorders

Plans Ensuring Mental Illness Treatment

With a stringent mandate issued by IRDAI, all health insurance plans automatically include the coverage of mental illness coverages. But there are a number of plans available in the market which are being one step ahead by clearly mentioning about the kind of mental disorders tackled by their policies to support their customers. Here are those plans.

Here Is The List Of Top Plans Covering Mental Illnesses-

  1. Activ Health Enhanced

    Aditya Birla Health Insurance launched an initiative of up to 100 percent health insurance premium returns and allied product offering upgrades under a newer version of its Activ Health policy. Known as Asia's first ever health insurance plan offering mental illness counselling coverage, this plan covers counselling for mental health illness which is traditionally excluded in medical policies.

    India's first health insurance plan rewarding consumers up to 100% of their health insurance premium as HealthReturnsTM - maximise earnings by leading a healthy life. Day 1 cover for Chronic illnesses like Asthma, High Blood Pressure, High cholesterol and Diabetes. Double Sum Insured in 2 claim-free years- earn 50% No Claim Bonus for every claim-free year - max up to 100% of Sum insured.

    Key Features of Activ Health Enhanced

  2. Niva Bupa's GoActive Plan

    GoActive by Niva Bupa is a holistic health insurance plan that has been designed to give customers 360 degree coverage for their daily health needs including inpatient hospitalization and on-the-go access to OPD, diagnostics, personalized health coaching, 2nd medical opinion, behavioral counseling and much more.

    This Plan offers savings to customers from day 1 including a complimentary complete body check-up up to INR 2500 per adult, diagnostics and cashless/reimbursement OPD coverage. The plan also offers benefits such as a renewal discount of up to 20% on achieving their health goals. Additionally, it introduces AdvantAGE - a 10% discount on base premium at the time of buying and on all future renewals if the age of the eldest enrolled person is below 35 years.

    Key Features of Niva Bupa GoActive plan

  3. Manipal Cigna's ProHealth Insurance

    It is a complete medical and health policy, designed to provide full protection against any ailment or medical emergencies. The plan comes with different variants viz., ProHealth Protect, ProHealth Plus, ProHealth Accumulate Large Cover, ProHealth Preferred, Prohealth Premier. This plan comes with coverage from Rs. 2.5 Lakh onwards which takes care of your hospitalisation, day-care procedures and domiciliary treatments.

    It features Health Maintenance Benefits, Cumulative Bonus, Restoration of Sum Insured, Worldwide Emergency Cover, Health check-up on every renewal, Expert Opinion on Critical Illnesses and Comprehensive cover - up to Rs.1 crore. The plan caters to all unforeseen health complications, maternity benefits and cover expenses related to the medical treatment of the newborn.

    Know More About: Manipal Cigna's ProHealth Insurance

  4. Check Health Insurance Premium
    Check Health Insurance Premium
  5. HDFC Ergo's Critical Illness Plan - Platinum

    This plan offers coverage for 15 critical ailments includingAlzheimer and provides a lump sum payout on diagnosis of the illnesses covered under the policy. This health care provides policyholders with a lump sum amount after the initial diagnosis, provided the policyholder survives a 30-day survival period. The lump sum amount provided covers the cost of the treatment, recuperation aids, provides reimbursement for income loss suffered due to the diagnosis and is also useful for paying off any debts but comes with a 90-day waiting period before raising a claim.The plan permits enrollment of people starting from the age of 5 to 65 years.

    List of disease covered under HDFC Ergo Critical Illness Plan - Platinum

  6. Niramaya Health Insurance Scheme for Disabled Persons

    This Scheme is being offered by The National Trust in collaboration with ICICI Lombard, a private insurance company. The National Trust is a statutory body constituted by enactment of an Act of Parliament by the Government of India, for the Welfare of Persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities.

    This scheme offers same premium of Rs. 1 Lakh per beneficiary, irrespective of the age of the person and same coverage for all irrespective of the type of disabilities covered under by The National Trust. Insurance is guaranteed. No "selection" will be made. Every persons with developmental disabilities and enrolled with The National Trust will be eligible for insurance. There is no exclusion will be made because of pre-exisiting condition and requires no medical tests before providing the insurance cover.

    This covers regular medical check up, hospitalization, therapy, corrective surgery, transportation, repetitive medical intervention as an in-patient, pre and post hospitalization expenses. OPD treatment can be taken from any qualified Medical Practitioner. In-patient (i.e. admitted in hospital) treatment can be taken from any hospital. The cost will be reimbursed (subject to the insurance limit)

    Company NamePlan Name Premium -1 YearSum Insured
    HDFC Ergo Health InsuranceHDFC Ergo Critical Illness Platinum planRs 41305 Lakh
    Reliance General Insurance Health Gain Insurance PolicyRs 69316 Lakh
    ManipalCigna Health Insurance ProductsManipal Cigna's ProHealth InsuranceRs 74225.5 Lakh
    Aditya Birla Health InsuranceActiv Health EnhancedRs 73375 Lakh

    *Premium is for 30 years old non smoker male

Available in Individual as well as Family Floater Plans, the plan offers comprehensive coverage with in-patient treatment, and several add-on features.

Unique Features

  • Avail waiver of premium
  • Consumables Covered
  • Cumulative Bonus of 33.33%

Health Gain Insurance Policy (Pros)

  • Second Opinion Cover
  • Vaccination Cover
  • Health Check-up Cover
  • Home Care Treatment
  • Vision Correction Cover

Health Gain Insurance Policy (Cons)

  • Unproven Treatments Unavailable
  • Overseas treatment Unavailable
  • Hazardous Activity not covered
  • Infertility Treatment not covered
  • Cosmetic Surgery unavailable

Health Gain Insurance Policy (Other Benefits)

  • Companion Cover
  • Child Care Cover
  • Radio Taxi Cover
  • Convalescence Cover
  • Air Ambulance Cover

Health Gain Insurance Policy (Eligibility Criteria)

  • Entry Age - 18 Years
  • Max Entry Age - 65 Years
  • SI - 3 L to 1 Cr
  • Waiting Period - 30 Days

A comprehensive Plan with 5 different variants suitable for individuals and young couples, offering a sum insured up to 1 Crore.

Unique Features

  • Avail Family Discount
  • Worldwide Emergency Protection
  • Avail Healthy Lifestyle Benefits

Manipal Cigna Pro Health (Pros)

  • 5 Plan Variants
  • SI Up to 1 Crore
  • Hospital Cash Benefits
  • Up to 200% Cumulative Bonus
  • Avail Health Check-Up

Manipal Cigna Pro Health (Cons)

  • Optional Co-Pay
  • Injuries due to unlawful activities
  • Obesity
  • Cosmetic Surgery
  • Injuries due to illegal activities

Manipal Cigna Pro Health (Other Benefits)

  • 8500+ Cashless Hospitals
  • Tax Benefits
  • Inflation Protection
  • Medical Check Up Cover
  • Health Reward Points

Manipal Cigna Pro Health (Eligibility Criteria)

  • Entry Age - 91 Days
  • Max Entry Age - No limit
  • SI - 2.5 L to 1 Cr
  • Waiting Period - 30 Days

NivaBupa Go Active

A modern-day digital insurance plan offering you cashless OPD and diagnostic services along with basic coverage and healthcare benefits.

Unique Features

  • Early age enrolment discounts
  • Annually 10 OPD consultations
  • No room rent capping

NivaBupa Go Active (Pros)

  • Pharmacy and Diagnostic Services
  • Domiciliary hospitalization
  • Personal Accident Benefit
  • Refill Benefit
  • Daily health coaching

NivaBupa Go Active (Cons)

  • Maternity Benefit Not available
  • Adventure Sports not covered
  • HIV/AIDS not covered
  • Cosmetic Surgery Not Covered
  • War Injuries not covered

NivaBupa Go Active (Other Benefits)

  • Behavioural Assistance Program
  • Alternate Treatment
  • I-Protect option to increase SI
  • 2 % ICU Cover (per Day)
  • No Room Rent Sub Limit

NivaBupa Go Active (Eligibility Criteria)

  • Entry Age - 18 Years
  • Max Entry Age - 65 Years
  • SI - 4 L to 25 L
  • Waiting Period - 30 Days

Important Things to Notice

With people are being vocal about psychiatric issues, the insurance sector is also inching towards preparing a comprehensive plan to provide aid against different nature of mental illnesses. Currently, working towards building constructive plans, the health insurance companies have also put caps on the facilities offered in their health care plans in the form of various sub limits or exclusive with regards to the mental illness.

From the above definition, it is clear that mental retardation is excluded. The Act includes mental conditions associated with the abuse of alcohol and drugs. However, this has been put under exclusions by almost all insurers.

In case, there is pre-existing mental condition with the customer, either it is not covered in the policy or the plan is modified according to their health conditions.

The waiting period is a big tool that has been used to keep the mental illness expense at the bay for some time. In fact, some of the plans have a clear restriction on the percentage of the sum insured to be spent on a mental illness.

There could be few more exclusions specific to mental illness and also certain waiting periods for some of the illnesses, these remain to be seen. As of now, most brochures and policy documents exclude mental illness in this way - "Treatment of any mental or psychiatric condition including but not limited to insanity, mental or nervous breakdown / disorder, depression, dementia, Alzheimer's disease."

Hence, it is always advised to thoroughly read, analyse and compare different plans in order to select the right one which is suitable for your mental health condition.

Case Study

Recently, a policyholder of Niva Bupa Health Insurance, who has been paying premium for a sum insured INR 35 Lakh, was denied claim settlement raised for the mental treatment. The condition given to him by the insurer stated that in case of a mental illness the sum assured is restricted to ₹ 50,000.

When the insured approached the Delhi High Court to seek justice, the apex body referred the Mental Healthcare Act of 2017, an act that clarifies that there can be no discrimination between mental and physical illnesses and the insurance provided in respect thereof.

While the matter is pending with the apex body as of now but concurrently, the Delhi High Court has notified that "this matter requires consideration, in as much as the Insurance Regulatory and Development Authority of India ought to place on record the basis on which approval has been granted for such insurance policies".

What Does Mental Health Insurance Cover?

As insurance becomes mandatory for every insurance provider to offer to its customers, here are the details of what a mental health insurance policy will cover:

  • All the major mental health issues
    A mental health insurance will cover most of the diseases that fall into the category. Ranging from anxiety, depression to complex and difficult to identify and treatments, every issue related to mental sickness is covered under such policies.
  • Inpatient and outpatient procedures
    Earlier, the health insurance companies only covered hospitalization expenses that rose out of mental health issues. Mostly, the mental health issues are corrected by behavioral therapies and thus require OPD. As the government guidelines have changed, now inpatient and outpatient procedures are well covered by these policies.
  • All other medical expenses
    Sometimes, the treatment is not confined to the hospital and therefore, the new age mental illness cover involves pre and post hospitalization charges, treatment recovery, medical tests, and much more as specified in the plan.
  • Companies have a list of mental illness that is borne by them, these are some of the known diseases that fall in the list of mental illness: Acute Depression, Bipolar disorder, Schizophrenia, Anxiety disorders, Obsessive-compulsive disorders, Attention-deficit/hyperactivity disorder, Post-traumatic stress disorder, Mood disorder, Psychotic disorder.
  • Policyholder's hospitalization and therapy expenses towards treatments of mental illnesses will be covered too.
  • Diseases like depression, dementia, bipolar disorder and Alzheimer's shall be covered with some exclusions, decided by the insurer.

What Does Mental Health Insurance Not Cover?

For persons with mental illness, it is advised to carefully read through your policy paperwork, the policy terms and conditions, and the policy exclusions, in order to understand how insurance companies have built policies that provide the best health insurance for mental health coverage.

Insurance companies have designed their policies for people with mental illness, it is recommended to go through your policy documents, and the policy terms and conditions carefully and understand the exclusions.

There are a few specific exclusions to some mental illnesses in health plans let us go through them one by one:

  • Similar to pre-existing health conditions, you would have to look out for pre-existing mental disorders and check the clauses of the plan as very few companies cover mental disorders with a very long history. They may even charge high premiums.
  • Mental retardation experienced by the individual and the mental illnesses arising out of the abuse of drugs or alcohol is not covered under mental illness.
  • Mental health insurance only covers expenses such as hospitalization but outpatient treatment like consultations are not covered in most of the plans.
  • Every plan has a waiting period for specific mental disorders, kindly check and then opt for the plan as no compensation will be paid before the waiting period.

Things to Know About Mental Health Insurance

According to the WHO report on mental health, India has one of the world’s largest populations of people with mental issues. Almost 15% of Indian adults need treatment for one or more mental health issues. So after analyzing this situation IRDAI has laid new guidelines for the insurance companies. Let's see a few things that we must know about Mental Health Insurance Coverage:

  • As per new guidelines Insurance companies in India cannot simply reject new policy applications for people with mental illness.
  • Insurance companies must include mental illness in their health insurance policies.
  • Few insurers and policies even cover consultations and counseling for mental illness, and this is covered under the OPD benefit of health insurance.
  • More critical diseases like depression, dementia, bipolar disorder and Alzheimer's are also covered by a few insurance companies.
  • Mental Health Insurance Coverage also includes hospitalization and therapy expenses, this includes diagnostics, medications, treatment costs, room rent and even road ambulance charges.
  • Companies generally provide mental illness benefits with a waiting period ranging from 90 days to 2 years. This depends on the policy you opted for, check the details of the policy before buying.
  • To raise the claim for hospitalization, the minimum time of hospitalization for a mental illness patient has to be 24 hours.

How To Verify If Your Insurance Provider Covers Mental Illness?

Register and log on to your insurance account online

Your health insurance plan website should contain information about your coverage and costs you can expect. Since insurers offer a variety of plans, make sure you're logged on and viewing your specific insurance plan.

If you're required to choose a treatment and hospitals that's in your plan's network, a list of providers should be available online.

Call your insurance provider

If you need additional information, call the toll-free number on the back of your insurance card and ask questions about the types of mental or behaviour assistance program services you can expect coverage for, as well as any out-of-pocket costs you may incur.

Ask the therapist

Therapists, counsellers and other mental treatment related hospitals often change the insurance plans they're willing to accept and may have opted out of your plan.

Claims Process of Mental Health Insurance

It is very important to know about the claims procedure of a particular plan in order to avoid future discrepancies. The claims process for mental health insurance is as follows:

Step 1: The first step in the claims process is to seek diagnosis and treatment from a qualified mental health professional. They will provide the necessary documentation and medical records to support your claim.

Step 2: Once you have received the required treatment, contact your insurance provider to initiate the claims process.

Step 3: Prepare the necessary documents, which may include medical reports, prescriptions, invoices, and treatment receipts.

Step 4: Fill out the claim form provided by the insurance company accurately and provide all the requested information.

Step 5: Submit the completed claim form along with the supporting documents to the insurance provider within the specified time frame mentioned in your policy.

Step 6: The insurance provider will review your claim and assess its validity based on the submitted documentation. If necessary, they may also ask for clarification or further details.

Step 7: If your claim is approved, the insurance provider will process the claim and provide the reimbursement or payment for the covered expenses as per the terms of your policy.

Exclusions of Mental Illness Coverage

When it comes to mental health insurance coverage, it is crucial for individuals with mental illness to thoroughly review their policy documentation, including the terms, conditions, and exclusions. Here are some important points regarding policy exclusions for mental health insurance:

  • Pre-existing mental illnesses: If you have a pre-existing mental illness, your insurance policy may not cover it for a certain period. The duration of this exclusion period may vary from insurer to insurer.
  • Self-inflicted injuries: If you intentionally harm yourself, such as in the case of attempted suicide, your insurance policy may not cover the costs associated with the treatment of any injuries sustained.
  • Substance abuse: Mental illness coverage policies may not cover the treatment of mental health issues caused by substance abuse or addiction.
  • Experimental treatments: Treatments that have not been widely acknowledged by the medical community are considered experimental and may not be covered by mental health insurance coverage.
  • Alternative therapies: Some alternative treatments, like yoga, acupuncture, and hypnosis, could not be covered by mental illness coverage.
  • Mental Retardation arising due to substance abuse: Mental illness health insurance generally does not cover mental retardation or mental illnesses arising from drug or alcohol abuse. So it is very necessary to differentiate between inherent mental health conditions and those resulting from external factors.
  • Outpatient Treatment: While mental health insurance may cover hospitalization expenses, it is important to note that outpatient treatments such as consultations and therapy sessions may not be covered by most plans.
  • Waiting Periods: Many mental illness plans have waiting periods specifically for certain mental disorders. It is essential to check the policy details and be aware that no compensation will be paid for treatment related to these specific disorders during the waiting period. It is essential to review the policy to understand the extent of the outpatient coverage provided.

Mental Illness Covered in a Health Insurance: FAQs

1. Is there a specific type of insurance plan that covers mental illness?

Mental health coverage is often included in comprehensive health insurance plans, including both family floater and individual plans.

2. Are there any limitations or restrictions on mental health coverage?

Some insurance plans may have limitations on the number of therapy sessions covered, require pre-authorization for certain treatments, or have restrictions on specific medications.

3. Can I use my insurance for both inpatient and outpatient mental health treatment?

Yes, insurance coverage can apply to both inpatient and outpatient mental health treatment, although specific coverage details may vary.

4. Does insurance cover alternative or complementary treatments for mental illness health insurance?

Insurance coverage for alternative or complementary treatments, such as acupuncture or herbal remedies, may vary and typically has more restrictions.

5. What is the minimum and maximum age for Mental illness coverage?

There is a minimum age requirement of 18 and a maximum age limit of 65 or no upper age limit; this will entirely depend on the company.

6. Who needs cover for mental health?

An individual with these symptoms of Acute Depression, Bipolar disorder, Schizophrenia, Anxiety disorders, Obsessive-compulsive disorders, Attention-deficit/hyperactivity disorder, Post-traumatic stress disorder, Mood disorder, or Psychotic disorder needs cover for mental health.

7. What is the waiting period for mental health insurance coverage?

Generally, the waiting period for mental health coverage ranges from 90 days to 2 years, it depends on the insurer and the policy you have opted for.

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Naval Goel

Reviewed By: Naval Goel

Naval Goel is the CEO & founder of Naval has an expertise in the insurance sector and has professional experience of more than a decade in the Industry and has worked in companies like AIG, New York doing valuation of insurance subsidiaries. He is also an Associate Member of the Indian Institute of Insurance, Pune. He has been authorized by IRDAI to act as a Principal Officer of Insurance Web Aggregator.