Narjis Husain

The mother of two children today, Ritu (name changed), says, “I was extremely worried with regard to the studies of my second child when she was promoted to tenth class, as she was not sincere in studies. During this period, due to some reasons there was also tension and bickering within the family, and I had to consult psychiatrist three to four times in a month, and that was quite expensive for me.” She however took full treatment and also followed the doctor’s advice in every respect –medicines, rest, diet, mind/ thought and conduct – that helped in reducing my depression a great deal but caused me great money crunch for a considerable time.
Everyone knows that in a metro city like Delhi, one consultation with a psychiatrist/ counsellor costs somewhere around 1500/- rupees, as these mostly work in the private sector. Therefore, four sittings in a month would entail an expenditure of Rs.6000/- that is not reimbursed by the insurance company. At least to begin with, the mental ailments mostly require consultancy – and not hospitalization – and are mostly cured in the process. It would take some time before the data pertaining to the expenditure, being incurred by the people on outdoor consultancy for mental ailments, becomes known.

Abhishek Jain, the co-founder of CreditSathi.com, says that “the inclusion of mental health in the insurance cover would help improve awareness about it, make people understand its importance and also encourage education in this area. With regard to the Out Patient Department (OPD) counselling sessions, the insurance companies can certainly decide the number of consultations per month to be covered, but if the counselling is kept completely out of the purview of the mental health insurance then why would a mental health patient go for health insurance.” Sharing his experience of working in the insurance sector of the United Arab Emirates (UAE), Abhishek informs that there also the insurance companies have started including mental health the focus is on mental health in the health insurance package, but highlights that there the focus is on mental health counseling only.

In this regard, Saumitra Pathare, Director, Centre for Mental Health Law and Policy, says that “Through the law, the parliament has decided to treat the mental health patients with regard to treatment and insurance cover on an equal footing with the patients suffering from other ailments. Here, what needs to be underlined is that the law has treated them as equal.” The psychiatrist, Saumitra, having been an active member of the drafting team of the Mental Healthcare Act 2017, considers it a laudable positive initiative, whereas the mental health activist, Advocate Gaurav Kumar Bansal is of the view that “today almost every country in the world is providing mental health cover under health insurance to her citizens, whereas India is the only country where there is too much noise in this regard, but there is nothing on ground. It is however true that the government included mental health in the health insurance through the framing of the law and its operationalization. It is necessary that now the government implements it at every level. Unfortunately even the Insurance Regulatory and Development Authority of India (IRDAI) – that has every power to exercise control over the insurance companies – was sitting quiet for over two years”.

On July 15, 2019, Santokh Singh, MP, asked a two-fold question in the Lok Sabha, where he asked for the number of beneficiaries under the mental health insurance, and also asked about the steps taken by the government to cover the maximum possible number of people under mental health insurance. In a pathetic response, the government did not provide real answers to the questions and beating about the bush, the Finance Minister informed the House that after issuing the 2018 circular, the IRDAI has given approval to the 110 products covering mental health. But IRDAI was unable to provide specific answer. The Hon’ble Minister could only inform that since 2018, the health insurance companies under the government sector have provided health cover – that includes mental health also – to around one lakh people.

Private/ Government Sector and the Requirement of Insurance Cover for Mental Health
Presently the Health Insurance covers only hospitalization and nothing else – though the expenditure on OPD treatment is an important part of the expenditure on mental health, but that has not been covered so far.In our country, the Health Insurance works under two distinct sectors – governmental and private.
In the private sector, all the big companies like HDFC ERGO Health and ICICI Lombard – for different products – charge (pre-determined) different premium at the given frequency, and provide health insurance to the people. Obviously, but importantly, enough, these companies charge premium according to the risk-level and the facilities provided – and not according to the paying capacity of the customer. That is greater the cover or greater the risk-factor, higher the premium – whatever may be the paying capacity of the individual!
The benefit of the health insurance under governmental sector – in contrast to the private sector – goes to the poor people, the ones living on the margins. Normally, there is no premium in these schemes – such as Rashtriya Swasthya Bima Yojana, Central Government Health Scheme (CGHS), Employees’ State Insurance Scheme (ESIS), Aam Admi Bima Yojana and Ayushman Bharat (Pradhan Mantri Jan Arogya) Yojana – and the expenditure is borne by the Central and State governments. In the government sector, there is also General Insurance Corporation, which has fully owned four subsidiaries – namely, National Insurance Company Limited, The New India Assurance Company Limited, The Oriental Insurance Company Limited, and United India Insurance Company Limited – that provide different health products to the people. However the premium for these products is to be paid by the beneficiary.
According to the National Mental Health Survey (NMHS) 2015-16, at any given time, roughly 11% population of our country suffers from different mental health issues – such as depression, anxiety, other serious/ normal mental health issues, or substance use disorder. It is not that the treatment for these ailments is not available, but there is huge disparity between the number of people requiring treatment and the availability of the doctors. NMHS also says that, in case of substance abuse, serious depression and neurosis, 86.3%, 85.2% in, and 83.2% people do not have access to treatment. In addition to the foregoing, the huge expenditure that the treatment of mental health issues entails is a great hindrance in taking the treatment and recovering from the ailment. Therefore, with regard to the treatment of mental health issues, this decision to provide the coverage of mental health under the health insurance provides a ray of hope to a large number of people.


Government’s Expenditure on Insurance Sector

Presently, on the health sector, the government is spending only 1.15% of the Gross Domestic Product (GDP); and, that is quite less in comparison to the rest of the world. Almost 80% of the people are dependent on the very expensive private health sector. And, it is this expensiveness that very many people are unable to afford the healthcare. The records of the National Sample Survey Organization (NSSO) inform that because of the lack of the resources, 20% of the city population and 28% of the village people are unable to afford any treatment. In our country, the spending on health out of pocket by the central, state and local governments, all put together, is around 20% and the rest 71% is borne by the people themselves. According to the 2012 World Bank Report, on the health sector in India, the Union Government spends only 3.6% of the total expenditure, which is substantially less compared to the other low-income countries, and that is the reason for low financial security in health here. The Indian Life and Health Insurance Sector Report informs that up to 2017, of the 1.3 billion Indians, only 44% had the Health Insurance cover; and, the government share in the health services was 30%,with the private sector accounting for the rest 70%.

Insurance Exists, But Implementation is Missing!

The mental health has been undoubtedly brought under the health insurance – but no attention has been paid towards the issue of its implementation, or realization in actual practice. That is precisely the reason why, from time to time, questions are raised on this issue. So long as the patient is not suffering from some very serious or extreme mental health issue, the patient is not admitted to the hospital; and, even when the patient is admitted to the hospital, s/he requires repeated consultations and medication for extended period after her/ his discharge from the hospital. Will these consultations and medication, subsequent to the discharge of the patient from the hospital, be included in the insurance?
In case of a physical ailment, the insurance companies charge the premium according to the pre-existing health condition and the chronic nature of the ailment. How these aspects of pre-existing health and chronic nature would be taken care of in case of the mental health issues would be a contentious issue. In case of mental health patients, the rehabilitation, psychotherapy and counselling are also involved – and these continue for months – will these be covered by the insurance companies? What sort of mental health treatments or aspects have not been covered under the health insurance? Section 115(2) of the law stipulates that if due to extreme depression a person makes an attempt to commit; then, in case of the attempt being unsuccessful, then it is the duty of the government to take care of such a patient. Will the Insurance Companies take such a responsibility? The foregoing questions will however remain an unresolved puzzle, so long as the government, the judiciary and the insurance companies do not reach a consensus regarding these.