Mental health plays a crucial role in a person's overall well-being. Till a few years ago, health insurance prioritised coverage for physical ailments, with mental health coverage becoming more prevalent only recently. Treatment for mental illnesses can be expensive and can require a level of care comparable to that for physical conditions. Therefore, having health insurance with mental health benefits is essential. Continue reading to learn more about mental health insurance plans available today.
 

Is Mental Health Coverage Available in India?

For a long time in India, health insurance plans did not cover medical expenses related to mental illnesses, focusing only on physical health issues. However, recent years have seen a significant shift in this approach. There has been increasing awareness and openness about mental health concerns, prompting more individuals to seek help.

This shift culminated in the enactment of the Mental Healthcare Act in 2017, effective from May 29, 2018. Subsequently, the Insurance Regulatory and Development Authority of India (IRDAI) mandated all insurance companies to include mental health coverage in health insurance policies. Despite these regulations, many insurers initially did not update their policies to include mental health coverage widely.

The COVID-19 pandemic further emphasised the importance of mental well-being alongside physical health. According to the World Health Organization, approximately 7.5% of the Indian population experienced mental disorders by October 2020. To address these issues comprehensively, IRDAI directed insurers to amend their health insurance plans to cover treatment costs for mental illnesses by October 2020. However, there were delays in implementation, leading to a final directive from the insurance regulator to ensure coverage for mental health treatment by October 31, 2022.

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Which Conditions Fall Under Mental Health Coverage in Health Insurance?

Health insurance policies now include coverage for a variety of mental illnesses that can impact memory, thinking, behaviour, and decision-making abilities. These may include:

• Schizotypal and delusional disorders
• Schizophrenia
• Obsessive-compulsive disorder
• Hyperactivity/attention deficit disorder
• Mood disorders (such as bipolar disorder and depression)
• Stress-related disorders (like post-traumatic stress disorder)
• Neurotic disorders (including anxiety disorders)
• Acute and transient psychotic disorders
• Somatoform disorders (such as somatization disorder)

It is important to note that the specific scope of mental health coverage and the types of mental illnesses covered can vary between insurance providers. You can find detailed information about the illnesses covered and the extent of coverage in your policy documents.

What Do Mental Health Benefits in Health Insurance Include?

Health insurance now covers all expenses related to mental illness in a manner similar to how it covers hospitalisation expenses for physical illnesses or injuries. Most plans are structured to provide coverage for both inpatient and outpatient treatments, often with a substantial sum insured. Under these plans, expenses for pre- and post-hospitalisation, recovery, treatments, diagnostic tests, and examinations are typically included. Some policies also extend coverage to treatments addressing issues such as impaired decision-making, memory problems, mood disorders, and perceptual disorders.

What is Not Included in Mental Health Coverage?

Similar to other health insurance plans, mental health insurance also has specific exclusions. Notably, exclusions are situations or conditions for which the policy does not provide coverage. It is crucial to understand these exclusions to avoid claim rejections. Here are common exclusions for mental health insurance:

• Mental health insurance doesn’t cover conditions that are not clinically proven. Insurance coverage typically requires a confirmed diagnosis and supporting tests that indicate a specific mental illness.
• Typically, treatments that do not require hospitalisation may not be covered under the policy.
• Treatment for mental retardation is often excluded from coverage.
• Insurance may not cover mental illnesses that are directly caused by alcohol or drug abuse.
• Pre-existing conditions or a history of recurring mental illness may be excluded from coverage under certain policies.

Things to Know About Mental Health Services Coverage

Here are some important points to understand about mental health coverage in health insurance:

• Coverage Limited to Hospitalisation: Health insurance primarily covers mental illness expenses when you require hospitalisation as an in-patient. This includes room rent, medical treatments, and related expenses incurred during your hospital stay.
• Exclusion of OPD Treatments: Outpatient department (OPD) treatments, which involve day-to-day consultations and minor treatments not requiring hospitalisation, are typically not covered unless explicitly stated otherwise in the policy documents. This means costs for therapy sessions with counsellors or medical professionals outside of a hospital setting may not be covered.
• First Hospitalisation and Diagnosis: Some insurers require that the first hospitalisation and diagnosis for a mental illness occur during the policy period for coverage to apply. If you were diagnosed or hospitalised before purchasing the policy, certain insurers may not cover these expenses.
• Treatment by Qualified Providers: Insurance coverage for mental illness typically applies when treatment is provided by a qualified psychiatrist or a practitioner with specific postgraduate qualifications in related fields, as outlined in the policy.
• Coverage Limits: The extent of coverage for mental illnesses varies across insurers. Some policies may cover up to the sum insured chosen by you, while others may limit coverage to a percentage of the sum insured or a specified amount.
• Prior Approval Requirement: Certain insurance policies may require prior approval from the insurer before covering mental illness expenses related to hospitalisation. Emergency situations, however, may be exempt from this requirement under some policies.
• Waiting Periods: Many health insurance plans impose waiting periods for coverage of mental illnesses, typically ranging from 24 to 48 months. During this period, expenses related to mental illnesses may not be covered, and you would need to pay for these out of pocket. Some plans, however, may not have such waiting periods.

Conclusion

Mental health coverage under health insurance in India has evolved significantly in recent years, reflecting a growing recognition of its importance in overall well-being. Historically overshadowed by coverage for physical ailments, mental health treatment is now mandated by the Mental Healthcare Act of 2017 and regulated by IRDAI. This legislative push has compelled insurers to broaden their coverage to include various mental illnesses, ranging from mood disorders to psychotic conditions. While coverage typically includes both inpatient and, to a lesser extent, outpatient treatments, exclusions such as non-clinically proven conditions and treatments not requiring hospitalisation apply. It is crucial for policyholders to understand these nuances, including coverage limits, requirements for initial diagnosis during the policy period, and potential waiting periods for coverage initiation.

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