Status of inclusion of mental illness under health insurance coverage in India – An exploratory study

Abstract

Background:

The Mental Health Care Act, 2017 led the Insurance Regulatory and Development Authority of India to issue directives which mandated every insurer to make provisions for treatment of persons with mental illness. While many insurance companies tried to adhere to the directives, the ground reality was far from desirable.

Aims:

An exploratory study was conducted with the aim of understanding the status of insurance companies toward the inclusion of mental illness under health insurance coverage in India.

Methods:

The study was done in two parts: (1) review of health insurance policies and (2) interview of insurance personnels about status toward including mental illness under health insurance. The data collected from the in-depth interviews were analyzed qualitatively using thematic analysis.

Results:

Thirty-three individual health insurance policies from both nationalized and private sector insurance companies from across India were reviewed. Out of the 33, 17 policies did not explicitly mention mental illness coverage in their inclusion criteria; 14 policies explicitly mentioned mental illness coverage in their inclusion criteria, and two policies explicitly mentioned mental illness coverage in their exclusion criteria. A thematic analysis of the interviews led to three global themes: Barriers in Providing Services, Methods to Reduce Barriers, and Readiness to develop a new product for persons with mental illness.

Conclusion:

The study helped understand the perspective of the insurance industry toward mental illness coverage under health insurance and suggested recommendations for alleviating the barriers in providing insurance services to clients with mental illness.

INTRODUCTION

In most low- and middle-income countries, a significant proportion of healthcare expenditure is borne by the individual and family out-of-pocket.[1,2] In comparison to the global average of 32%, the World Health Organization estimates that the out-of-pocket health spending in India is as high as 65.1% (percentage of the current health expenditure).[3] An analysis of nationally representative data from India indicates that 3.5% of the population lives below the poverty line, while 5% of households face catastrophic health expenses.[4] Health insurance is one such strategy to meet the health expenses of the middle socioeconomic people. According to the Health Insurance for India’s Missing Middle, the ability to pay does not always translate into a willingness to pay, and there are not enough supply-side providers and insurers to meet that demand.[5,6]

Chapter 2 of The Guidelines on Standardization of Exclusions in Health Insurance Contracts[7] by Insurance Regulatory and Development Authority of India (IRDAI) mentioned treatment of mental illness, stress, or psychological disorders and neurodegenerative disorders as an exclusion. With such a scenario, where multiple clauses in the medical underwriting made it difficult for the insured to make a claim, mental health insurance is a distant objective in a nation where over 30% of people lack basic health insurance.[8,9] Following a Public Interest Litigation[10] filed by advocate Gaurav Kumar Bansal mentioning the violation of the MHCA, 2017, the Supreme Court of India instructed IRDAI to introduce policies for mental illness by October 2020. “Despite repeated directions from the IRDAI to underwrite and formulate insurance policies for persons with disabilities, insurance companies have failed to follow through. While insurance companies raised the premiums by 40%–70% for most health covers in 2020 to expand their coverage to persons with disabilities following IRDAI’s orders, the new policies have hardly been formulated or introduced in the market.”[11] In a review of individual health insurance policies for mental health conditions in India as of June 2021, it was found that these existing policies with coverage for mental health conditions catered to the high-income group as they had the capacity to pay, while the government schemes such as Ayushman Bharat covered the needs of the poor people; it is the middle-income groups which were unable to meet their health insurance requirements and that the need of the hour is to have a comprehensive universal health coverage to ensure health insurance coverage for all.[1,12,13] The “missing middle” is a significant nonpoor population that is uninsured and is situated between the organized, relatively wealthy sector and the disadvantaged, lower-income sectors of society, which continue to be vulnerable to catastrophic and even impoverishing medical expenses.

There are various papers reviewing the various health insurance policies for mental health conditions. However, this article intends to explore the gap between the ideal and real practice by the insurance companies and to explore the status of the insurance companies to fill in the gaps in their commitment to the cause of mental illness in providing full coverage health insurance policies.

METHODS

The objectives of the study were: (1) to review health insurance policies which cover mental illness and (2) to understand the status of the insurance companies in including mental illness under health insurance coverage. An Exploratory Research Design using a Qualitative Approach was conducted, and six participants from health insurance companies who were in managerial positions with capacity to give information regarding the policies of their companies were interviewed based on data saturation. Care was taken to have a representative sample from public and private health insurance companies. The study was approved by the Institute Sub-Ethics Committee, and written informed consent was taken from all the participants for both participation and publication. The privacy and confidentiality of the data were maintained. Data were encrypted without any identification details of the participants for analysis.

Review of health insurance policies on mental illness

A review of the list of insurance companies was done between September 2022 and January 2023. The list of companies was taken from table 62 of the Handbook on Indian Insurance Statistics Part 3 (Health Insurance) 2021–22.[14] These are the nonarchived annual reports of 2021–2022 from the IRDAI website. The researcher looked at only individual policies and not at family or group floaters. A total of six government health insurance schemes [Table 1A] and 33 individual health insurance policies (excluding family or group floaters) were reviewed and have been presented in [Table 1B]. These policies were accessed from the open-access online websites of both nationalized and private-sector insurance companies. After having thoroughly read each insurance policy, the inclusion criteria of each health insurance policy were checked regarding the inclusion of mental illness and the waiting period for mental illness was also looked at and if any policy mentioned mental illness in its exclusion criteria.

Table 1A.

Review of Health Insurance Schemes and Policies

S. No.	Government Health Insurance Schemes	Product Explanation
1	Ayushman Bharat (National Health Package Scheme)	Ayushman Bharat (National Health Package Scheme) was launched in 2018 by the Government of India for families from lower socioeconomic status. The Pradhan Mantri Jan Arogya Yojana component provides cashless health insurance cover up to ₹5 lakh per family (no restriction of family size) per year.1 The scheme also covers mental illness and treatments like ECT, rTMS, other treatments.
2	Arogya Sanjeevani Policy - National	Arogya Sanjeevani Policy - National is a standard indemnity health insurance product, having sum insured up to 10 Lakhs available in both individuals as well as floater type, covering Allopathy & AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy) lines of treatment; pre and post hospitalization up to 30 days and 60 days, respectively, for the same disease/illness/injury for which hospitalization occurred. Excludes drug/alcohol abuse-related expenses but does not mention the inclusion of mental illness explicitly.
3	Jan Arogya Bima Policy	Jan Arogya Bima Policy covers reimbursement of hospitalisation expenses, domiciliary hospitalisation expenses for illness, disease, or injury sustained. The policy aims to enable the poorer sections of society. There are specific coverages for impairment of Persons’ intellectual faculties, and treatment of mental illness, stress or psychological disorders and neurodegenerative disorders. Any kind of psychological therapy or counselling is excluded.
4	Universal health insurance scheme	Universal health insurance scheme was launched countrywide in July 2003 with the objective of providing health care to the poorest section of society. The scheme was open to BPL and Non-BPL families. There are specific coverages for impairment of Persons’ intellectual faculties, and treatment of mental illness, stress or psychological disorders and neurodegenerative disorders. Any kind of psychological therapy or counselling is excluded.
5	Swasthya Sathi Scheme	Swasthya Sathi Scheme was launched by the West Bengal government in 2016. The scheme covers all pre-existing illnesses and critical medical illnesses. The scheme does not explicitly mention mental illness coverage. The exclusion criteria mentions that it does not cover any medical condition which does not require hospitalization.
6	Rashtriya Swasthya Bima Yojana (RSBY)	Rashtriya Swasthya Bima Yojana RSBY has been launched by the Ministry of Labour and Employment, Government of India, to provide health insurance coverage for Below Poverty Line (BPL) families. The objective of RSBY is to protect BPL households from financial liabilities arising from health shocks involving hospitalization. Unorganized sector workers belonging to BPL category and their family members (a family unit of five) are the beneficiaries under the scheme. The beneficiaries are issued smart cards for identification. They are eligible for in-patient health care insurance benefits designed by the respective State Governments based on the requirement of the people/geographical area. The total sum insured would be Rs. 30,000/- per family per annum on a family floater basis. Hospitalization expenses, taking care of most common illnesses with as few exclusions as possible. All pre-existing diseases to be covered. There is no explicit mention of mental illness or psychiatric disorders coverage.

Table 1B.

Review of Health Insurance Schemes and Policies

Insurance Company and Product	Product explanation	Inclusion of Mental Illness	Website Link
National insurance company- Mediclaim policy	This policy indemnifies for In-patient treatment expenses (minimum 24 hour hospitalization) and 140+ Day Care Procedures on Cashless/ Reimbursement basis during the policy period. The expenses incurred should be reasonable, customary and medically necessary.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://nationalinsurance.nic.co.in/en/health-insurance/national-mediclaim-policy-individual-plan
Oriental insurance company-mediclaim policy	Mediclaim Insurance is a Health cover which takes care of medical expenses following Hospitalisation/Domiciliary Hospitalisation of the Insured in respect of the following situations: (A) In case of a sudden illness (B) In case of an accident (C) In case of any surgery which is required in respect of any disease which has arisen during the policy period.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://orientalinsurance.org.in/individual-mediclaim-policy
SBI Health Edge	Single Comprehensive Plan variant with 9 Basic indemnity Covers and 18 Optional covers to stand in need of medical exigency.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.sbigeneral.in/health-insurance/health-edge-insurance
LIC Health Insurance	The researcher could not find relevant health insurance plans by LIC, apart from Jeevan Aarogya, which has been withdrawn since 2021	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://licindia.in/health-plans
ICICI Lombard health shield	The plan is described as a complete health insurance, covering in-patient treatment, pre and post hospitalisation.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.icicilombard.com/docs/default-source/policy-wordings-product-brochure/complete-health-insurance-(health-shield).pdf
Manipal Cigna Pro-Health Prime Insurance	It covers expenses beyond hospitalization. Doctor consultations, laboratory test and pharmacy make up for significant portion of healthcare expenses.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.manipalcigna.com/quick-quote/prohealth-insurance?campaign=PROFONL&source=SEARCH_ODC&medium=gs_prime_ads_brand_em_manipalcigna_pro_health_insurance&utm_source=GOOGLE&utm_medium=CPC&utm_campaign=PT_MCHI_PRIME_LTH_BRAND_EXACT_OCT22_PRIME_ADS&utm_content=pro_health_insurance
Niva Bupa Go Active plan	This plan covers OPD consultations along with In-Patient treatment and intensive unit care and pre and post hospitalisation cover along with day care treatment.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.nivabupa.com/content/dam/nivabupa/PDF/GoActive/Niva_Go%20Active_SS_v2.pdf
Care Supreme Health Plan	This cover aims to expand the healthcare safety net without paying hefty premium amounts. With expansive coverage, the policy takes care of major healthcare expenses like hospitalization, day care treatment and others.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.careinsurance.com/product/care-supreme?agentId=20004977&utm_source=google&utm_medium=cpc&utm_campaign=ht_ind_new-101_AD_CS_BT&utm_content=rta&utm_keyword=care%20supreme%20policy&s_kwcid=AL!10397!3!649694765902!e!!g!!care%20supreme%20policy&utm_term=19064107578&utm_adgroup=144851466718&gad=1&gclid=Cj0KCQjwy9-kBhCHARIsAHpBjHioMrLHiqnggeRTyrlD7qQq_DoymHgO22ExalxB_gH8ZC061lLX9IQaAj-iEALw_wcB
Reliance Health Gain Insurance	One of the key features of this cover is that the waiting perio can be reduced from 3 years to 1 year along with other treatment benefits.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.reliancegeneral.co.in/Downloads/Reliance_HealthGain_Policy-Brochure.pdf
Tata AIG Medicare	It is a product that protects against the financial implications of a wide variety of health-related expenses, ranging from those caused by minor illnesses and injuries to critical diseases.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.tataaig.com/health-insurance?&utm_source=Google&utm_medium=cpc&utm_campaign=EDM_Health_Search_Brand_Desktop&utm_content=[Tata_Aig_Medicare]&gclid=Cj0KCQjwy9-kBhCHARIsAHpBjHg-JfaUenbMllrJUcXewymKlbdpvXz4sJ7C920YKfTYGgB3ct2-S10aApswEALw_wcB&gclsrc=aw.ds
Navi Health Policy	This covers both pre and post hospitalisation cover along with In-Patient care and also OPD coverage.	Explicitly mentions Mental Illness coverage in their Inclusion Criteria.	https://public-assets.prod.navi-sa.in/Insurance+Migration/Downloads/1.Health_policy_doucment/Navi+Health/Navi_Health_-_Customer_Information_Sheet_final_R7DDtxN.pdf
Liberty Health Connect Policy	This plan covers In-Patient treatment along with Dy care treatment and other standard inclusions like pre and post hospitalisation treatment expenses.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.libertyinsurance.in/health-insurance/health-connect-policy.html
Royal Sundaram Lifeline	This plan covers In-Patient care along with pre and post hospitalisation expenses along with donor expenses.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://my.royalsundaram.in/health-insurance?gggj&utm_source=google&utm_medium=search&utm_campaign=AO-Brand-Health-EX-RLSA&utm_content={adgroupname}&utm_term=royal%20sundaram%20lifeline%20supreme&gclid=Cj0KCQjwy9-kBhCHARIsAHpBjHhKfZf4gU6EM5QYtwfRwDNz YyzCRhdATrYbuvWGnaF3SNTQTSUPJnoaAo23EAL w_wcB#compare-health-insurance
10L ACKO Platinum Health Insurance	The key features of this plan apart from standard inclusions like pre and post hospitalisation and day care treatment are zero waiting period and does not exclude treatment for drug abuse or alcohol use.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.acko.com/health-insurance/10-lakhs-sum-insured/
IFFCO Tokio Individual Health Protector	This covers for pre and post hospitalisation expenses along with ambulance expenses and cover for critical illnesses.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.iffcotokio.co.in/health-insurance/individual-health-insurance
Edelweiss Health Insurance Policy	The policy covers hospitalisation expenses, along with pre and post hospitalisation expenses and other standard inclusions.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://healthstatic.insurancedekho.com/prod/planpdf/20190704124339.pdf
Kotak Health Shield	It covers both early and major stages of cancer and life-threatening medical conditions related to the heart, liver, and nerves. The policy also provides financial protection against death or permanent disability due to an accident.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.kotaklife.com/insurance-plans/health-plans
Chola Healthline Privilege Plan by Cholamandalam MS General insurance	The plan covers standard inclusions such as expenses for pre and post hospitalisation, day care procedures along with special coverage for maternity and childcare expenses with standard exclusion criterias.	Do Not Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.cholainsurance.com/health-insurance/chola-healthline
Divyangjan Sanjeevani Policy by National Insurance Company	Divyangjan Sanjeevani Policy - National is a specially designed indemnity health insurance policy for persons falling under the following categories: Persons With Disabilities Persons affected with HIV /AIDS Persons affected with Mental Illness diseases. No pre-policy health check-up required.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://nationalinsurance.nic.co.in/en/health-insurance/divyangjan-sanjeevani-policy-national
Saksham Swasthya Policy by The Oriental Insurance Company	Given on individual basis only, along with standard inclusions of pre and post hospitalisation covers; the plan covers persons with 40% or more disability as per the RPWD, 2016 Act and also for persons with HIV/AIDS.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://orientalinsurance.org.in/documents/10182/10784600/Saksham+Swasthya+Policy_Prospectus+.pdf/55d4e4cd-466c-7769-ab80-6ba6dfb30d99
United India Insurance Medicare policy	The plan has a mental illness cover limit for schizophrenia, bipolar affective disorders, depression,OCD and psychosis along with other standard inclusion criteria like pre and post hospitalisation expenses.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://uiic.co.in/en/product/health/Family-Medicare-Policy
Star Mediclassic Insurance	The plan mentions Psychiatric and Psychosomatic coverage. Expenses incurred for the treatment of Psychiatric and Psychosomatic disorders for the first time are covered if the insured person is hospitalised for 5 consecutive days.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.starhealth.in/health-insurance/mediclassic/
Digit Health Care Plus Policy	Under section B7 the following psychiatric illnesses are covered such as schizophrenia, schizotypal and delusional disorders, mood(affective disorders), neurotic, stress related and somatoform disorders and unspecified mental disorder, with hospitalisation requiring prior approval.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.google.com/search?q=Digit+Health+Care+Plus+Policy&oq=Digit+Health+Care+Plus+Policy&gs_lcrp=EgZjaHJvbWUyBggAEEUYOdIBCDE2NjJqMGo0qAIAsAIA&sourceid=chrome&ie=UTF-8
Aditya Birla Activ health Platinum-Enhanced Plan	The plan mentions to be a comprehensive policy with mental illness hospitalisation covered, provided mental illness is clinically significant.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.adityabirlacapital.com/healthinsurance/campaign/activ-health-insurance-new?source=Smart_Brand_Search&utm_source=Smart_Brand_Search&utm_medium=Sok_Google_Pmax&utm_content=Sok_PMax_Activ_Platinum&utm_campaign=Sok_PMax_Performance_200922&keyword=&gad=1&gclid=Cj0KCQjw7uSkBhDGARIsA MCZNJsU4OsdmRQnHMJpNkmEcos02kNLKn2x6 RJCeYfg49wIolSvc7rC_fMaAhnzEALw_wcB#benefits
HDFC Ergo Health Suraksha	The plan covers mental illness hospitalisation along with standard inclusions for pre and post hospitalisation along with daycare treatment.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.hdfcergo.com/campaigns/health-insurance-detail-new?&utm_source=google_search&utm_medium=cpc&utm_campaign=Health_Search_Brand-Product_Neev-Phrase&utm_adgroup=Health-Suraksha&adid=600929275156&utm_term=hdfc%20ergo%20health%20suraksha&utm_network=g&utm_matchtype=p&utm_device=m&utm_location=9062005&utm_sitelink={sitelink}&utm_placement=&ci=googlesearch&SEM=1&gad=1&gclid=Cj0KCQjw7 uSkBhDGARIsAMCZNJv2xbSe KYX43OQZziqtmLvf8Henu4mqpa ESjoaqaI3NOVW9MLMsIbQaAiZkEALw_wcB
Universal Sompo A Plus Health Insurance	It covers cost of an insured member’s medical and surgical expenses. If during the policy period one or more Insured Person(s) is required to be hospitalized for treatment of an Illness or Injury at a Hospital/ Day Care Centre. One of the key features is coverage for psychiatric illness.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.universalsompo.com/assets/file/a-plus-health-insurance/a-plus-health-insurance-prospectus.pdf
Magma HDI One Health Plan	Psychiatric treatment cover is mentioned under Base covers along with In-Patient treatment and pre-post hospitalisation expenses.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.magmahdi.com/documents/20127/0/OneHealth+Web+Brochure_0919.pdf/c34a605f-d4f0-ed72-5657-d39e0abb98ef
Future Generali D.I.Y Health Insurance	The policy covers mental/psychiatric conditions along with cover for treatment of HIV/AIDS. The policy also has OPD cover.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://general.futuregenerali.in/buyonline/diy-health#section2
Health Bharosa by Raheja QBE General Insurance Company Limited	This policy covers all 21 disabilities mentioned under the MHCA, 2017. Along with cover for persons with HIV/AIDS.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.rahejaqbe.com/health-insurance/health-bharosa
Bajaj Allianz Individual Health Guard Insurance	The exclusion criteria specify mental illness, Parkinson’s disease.	Explicitly Mention Mental Illness Coverage in Their Exclusion Criteria.	https://www.bajajallianz.com/download-documents/health-insurance/health-guard/Health-Guard-Brochure-print.pdf
Atmanirbhar Health Policy New India Assurance	This indemnity type cover can be issued on individual sum insured basis only and is specially designed for persons with disabilities, persons with HIV/AIDS and persons with mental illness.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	file:///C:/Users/ZOYAA/Downloads/Atmanirbar%20Health%20Policy,%20NIA.pdf
Shri Criti Care Insurance by Shriram General Insurance	The policy mentions explicitly in the exclusions criteria that Intentionally self-inflicted injury or illness, sexually transmitted conditions, mental/nervous disorder, anxiety, stress or depression, Acquired Immune Deficiency Syndrome (AIDS), Human Immune-deficiency Virus (HIV) infection, suicide, are not included.	Explicitly Mention Mental Illness Coverage in Their Exclusion Criteria.	https://www.shriramgi.com/shri-criti-care-insurance/coverages
Reliance Specially Abled Health Scheme by Reliance General Insurance.	The policy has been specially made for the persons with mental illness and disabilities.	Explicitly Mention Mental Illness Coverage in Their Inclusion Criteria.	https://www.reliancegeneral.co.in/Insurance/Health_Insurance_Specially_Abled.aspx

Key informant interviews

The contacts of various company heads were searched on the company website and through the contact number provided on the website. After numerous no-response to emails, a total of six insurance personnels from different insurance companies at managerial positions across India (national and private insurance companies) were interviewed. After getting three interviews in the month of February 2023, there were no response from potential participants. Only in April 2023, after contacting and emailing 20 other potential participants, did three other participants agree for the interview. All the six participants were contacted through personal contacts and snowballing process. After an introductory call was made and verbal consent was taken, the Informed Consent Form was sent through e-mail and scheduled an interview according to mutual convenience of researcher and participant. The interviews were done using an interview guide which was prepared by SZ ensuring that the questions aligned to the objectives of the study were corrected by AJ, PR, and TS and was content-validated by three mental health professionals and two insurance professionals. These three mental health professionals and insurance professionals were selected based on convenient sampling. The insurance professionals were retired and were not actively attached to any insurance company at the time of validation. These professionals were not part of the final six participants. The interviews were conducted and transcribed in English online through Zoom, and an audio/video recording was done with prior consent. The interviews lasted a maximum length of 60 minutes.

Data analysis

The researcher analyzed the qualitative data using content and thematic analysis methodology using the six steps listed by Braun and Clarke, 2006.[15] The researcher started with identifying domains for analysis, including major and minor thematic areas. Initially, the researcher transcribed the interviews and evaluated the responses of participants. After that, the researcher assigned codes to each independent datum. The contents of the interview were independently coded, and themes developed according to the codes. The themes represent a patterned response or meaning within a data set. After reaching data saturation, the themes were content-validated by AJ.

RESULTS

This review helped to get a better understanding of the difference between compliance with the law/circulars on paper and in practice. The insurance companies which do not mention specifically mental illness in the policy want to make the consumers understand that there is an unsaid coverage; however, in practice, the wordings in the policy play an important role while buying a policy.

The table below has been divided into two parts: Part A illustrates a total of six government health insurance schemes, while Part B illustrates a review of 33 individual health insurance policies. The author procured these policies from the three categories of general and health insurance companies: public sector, private sector, and standalone health insurers (private sector), which provide health insurance policies and are registered under the IRDAI. The list of companies was taken from the nonarchived Handbook on Indian Insurance Statistics 2021–2022 under the IRDAI website.[14]

To understand the status of the insurance companies in including mental illness under health insurance coverage, the total number of participants is depicted as ‘n’, which is equal to 6 insurance personnels from different insurance companies at managerial positions across India (national and private insurance companies), who were interviewed. The four sociodemographic variables were (a) gender where male participants were 5 (83.3%) and female participants were 1 (16.6%), (b) type of company where there were 3 (50%) participants each from nationalized and private companies, (d) designation which had 4 (66.6%) participants at Senior Manager post, 1 (16.6%) participant at the post of Chief Underwriting Officer and 1 (16.6%) participant at the post of Director for Claims, and (e) state where 1 (16.6%) participant belonged to West Bengal, 2 (33.3%) participants belonged to New Delhi, and 3 (50%) participants belonged to Karnataka.

The interviews brought out three global themes and multiple subthemes depicted in [Table 2]. Three major themes that were derived from the interviews are ‘Barriers In Providing Services’ and ‘Methods to Reduce Barriers In Providing Services’ and ‘Readiness of the insurance companies to develop a new product for persons with mental illness’ with subthemes under each global theme that came through during the interviews with the participants.

Table 2.

Table of global themes and sub-themes

Barriers in providing services	Methods to reduce barriers in providing services	Readiness of the insurance companies to develop a new product for persons with mental illness
1. Systemic issues with health insurance in India which is not unique to mental illness •Hospital centric coverages •Lack of OPD/counselling coverages •GST on Health Insurance •Price-sensitive market •Corporate Social Responsibility does not seem feasible. 2. Issues unique to mental illness and their possible solutions •High cost of treatment •Risky smaller pools and low penetration •Lack of awareness of co-existing medical conditions. •Lack of professional knowledge/ access to medical person •Different slabs of premium not feasible for the private sector •Unclear guidelines from IRDAI •Need to look for existing models •Lack of proper documentation in patients’ medical records. •Problems with OPD coverages 3. Demand side barriers from prospective clients with mental illness •Stigma & lack of awareness faced by clients 4. Gaps in availability of data in devising new health insurance policies for persons with mental illness •Lack of data on claims due to nascency of the implementation of mental illness under health insurance	1.Reduced waiting period 2.Add-on cover for mental illness 3.Inclusion of OPD and psychological and psychosocial intervention coverages 4.Need for mental health experts. 5.Re-examine exclusion criteria 6.Low treatment charges 7.Nominal premium with maximum coverage 8.Proper research required 9.Adequate government aid 10. Create larger pool 11. Differential premiums possible with Government support 12. Create awareness 13. Inclusion of all kinds of services 14. Non-Discriminatory and Clear Underwriting	1. Need for data to design policies 2. Inhibition from Private health insurance companies 3. Need for government aid for maximum coverage for persons with mental illness 4. Clear Instructions from IRDAI

DISCUSSION

In a previous study by Singhai et al.,[1] various health insurance policies available for mental health conditions were discussed post the Delhi high court verdict for health insurance for mental illness. In an Issue Brief by the India Mental Health Observatory (IMHO) in August 2021, a systematic review of health insurance policies was done to determine the extent to which they comply with the provisions of the MHCA, 2017. A mapping of around 461 health insurance policies under both government and private insurers was done, out of which 270 policies were reviewed, and it found that six policies had explicit discriminatory wordings to exclude mental illness coverage.[16]

Under the global theme ‘Barriers in Providing Services,’ lack of professional knowledge/information was one of the major barriers to providing services found in the study. This study found that insurance professionals do not have adequate knowledge and understanding of mental illness through the information collected through the interviews. However, the insurance personnels were open to getting trained on understanding more about mental illness.

Stigma and lack of awareness among the public were major barriers in providing services. Social attitudes and stigma were also considered an exogenous factor affecting mental health’s insurability; the fear of stigma was also mentioned as a reason for underreporting of mental health conditions. In a study done in SCARF, Chennai, in collaboration with NIMHANS, out of 400 samples, 68% of the individuals mentioned that they knew about health insurance products but not that mental health insurance is also available.[17] The author also believes that there is lack of awareness regarding mental illness and low penetration of health insurance products among the general public. People also need to be aware of health insurance products, and misinformation and misconceptions regarding insurance need to be addressed.

However, under the Methods to Reduce Barriers in Providing Services, the subthemes derived were the need for OPD and therapy coverages. According to a Mercer Marsh Benefits (MMB)[18] survey of 226 insurers across 26 countries, two-thirds of insurers provided counseling sessions. However, in practice, these sessions were limited to 10 or fewer, leaving consumers more vulnerable to higher out-of-pocket expenses. The depth of coverage through checking the number of sessions and services included under coverage should be something to look for as there are many existing health insurance policies with mental illness coverage, but with such limitations. The author believes that the findings derived from the interviews were significant and adequate to understand the status of the health insurance personnel and the health insurance industry overall. The themes derived are similar to the factors mentioned in the report by The Geneva Association.[19]

The study also explored the readiness of the insurance companies to develop a new product for persons with mental illness. However, the author found that although some insurance companies had complied to the latest IRDAI circular of February 2023, there were still certain challenges faced by the health insurance industry to develop a new product. These subthemes were mainly ‘inhibition from Private health insurance companies’, ‘lack of clear Instructions from IRDAI’, and ‘need for data to design policies.’ In an article,[20] lack of data has been mentioned as a major problem for the insurance companies as data drives pricing. The insurance companies are unable to understand the demands and distribution channels of such products which do not have data to back it up.

However, by the end of this study in April 2023, 29 new health insurance policies specifically for mental illness after April 2023 were floated into the market due to a mandate by the IRDAI dated February 27, 2023.

Although no scientific papers were found exploring the opportunities for developing a new product, The Geneva Association reports regarding the insurance innovation to improve mental health by creating novel technologies to enable early intervention and prevention of mental illness, having customized mental health programs in group plans, and creating a mental healthcare continuum from wellness to management.[19]

The results of this study have important implications in advocating for a revision in the various existing health insurance schemes and helping health insurance companies be specific in their terminologies in alliance with the Mental Health Care Act (MHCA), 2017. Its recommendations were also submitted to the expert committee for matters related to mental health convened by the IRDAI in 2023, which was composed of members from the insurance industry and mental health professionals.

A significant number of persons with MI (with or without benchmark disability due to mental disorders) still face challenges in health insurance coverage for the treatment of mental illness on par with physical disorders that they may have. This appears to be primarily due to the following issues: Terms and definitions used by the IRDA in its communication with the insurers concerning mental illnesses pose challenges in comprehensive coverage for mental illness treatment; unclear and discriminatory underwriting related to mental illness coverage; lack of OPD and psychological therapy/counseling coverage; current standard exclusion criteria mention drug/alcohol usage and suicide, whereas suicide has been decriminalized by the MHCA, 2017; long waiting periods for pre-existing conditions after disclosing that they have a mental illness, that is, 24 to 48 months of waiting period; and poor awareness and lack of knowledge among the public all health insurance products are mandated to cover the mental illness treatment expenses on par with other physical conditions after MHCA 2017.

The foreseeable solutions that came under the purview of IRDAI were to define mental illness as per MHC Act 2017; this needs to be conveyed to all insurers for offering treatment coverage; To immediately revise the IRDAI circular dated 27.9.2019 “Guidelines on standardization of exclusions in health insurance contracts”,[7] where there is discrepancy and inconsistency between various clauses that relate to covering the treatment expenses of mental illness. Inclusion of OPD treatment and psychological therapy/psychosocial counseling; To explore the possibility of differential premiums with nominal charges with maximum coverages similar to the Niramaya Health Insurance Scheme with a nominal premium, ranging from rupees 50 to 500 per annum based on the socioeconomic status of the persons with disability; According to the Rights of Persons With Disabilities Act, 2016[21] under chapter 5 section 26, the clause of insurance schemes to be made by the appropriate government has been mentioned. Reduction in the waiting period after disclosing mental illness at the time of purchasing policy (least possible waiting period on par with other health considerations); To prepare a standard format in collaboration with mental health professionals to prepare a report on all medical/mental illnesses to help a patient/person apply for health insurance; This will help the insurance companies and the persons with mental illness before applying as mental illness is not objectively measurable and the fear of abuse and fraud may hinder insurance companies; To generate more awareness among the public about the coverage of mental illness under all health insurance schemes and to issue specific directions to the insurance ombudsman in this regard; To closely examine the high premium rates prescribed by the health insurance companies while offering coverage to persons with mental illness; To consider using the Pradhan Mantri Jan Arogya Yojana Ayushman Bharat (PMJAY AB) data for understanding the treatment expenditure for mental illnesses and to revise the coverage rates as may be needed; To closely examine the high premium rates prescribed by the health insurance companies while offering coverage to the persons with disability due to mental illness.

The solutions from a mental health and psychosocial perspective include having to develop an ecosystem to facilitate the continuum of care by liaising with mental health professionals such as psychiatrists, psychiatric social workers, psychologists, and psychiatric nurses to act as a bridge between the insurance sector and the public; To initiate a national helpline number to share information to the public along with earmarked grievance redressal personnels for addressing the issues related to rejections and examine if rejections are fair and on par with physical illness coverage; Adequate and appropriate health insurance coverage for treating mental illness on par with all other physical health conditions including the expenses for OPD treatment and psychosocial therapies; A revisit of all terms and definitions used by IRDAI and health insurers including a few age-old definitions such as injury and illness, which are defined from a physical health perspective and modify them wherever necessary to highlight that health includes mental health and emotional wellbeing; To consider creation of policy guidelines allowing the coverage of treatment for persons with mental illness in establishments with psychiatric rehabilitation services which focuses on regaining optimal recovery and functionality. To create awareness among health insurance companies regarding mental illness by conducting workshops by mental health professionals; To advance mental health policy, advocacy, and human rights by using media and community awareness regarding mental health insurance, and to aid in building strong political will to invest in health.

CONCLUSION

The study has found that it is feasible to have a product with mental illness coverage; however, it has its own barriers. These barriers can be overcome with adequate government aid and collaborations of all stakeholders for effective implementation. An all-inclusive perspective addressed in the Rights of Persons with Disabilities, 2016 and the MHCA, 2017 should be reflected effectively in all the health insurance policies of all companies under IRDAI.

Declaration regarding the use of generative AI

The authors attest that there was no use of generative artificial intelligence (AI) technology in the generation of text, figures or other informational contents of this manuscript.

Ethical considerations

This research proposal of the present study was approved by the Institute Sub-Ethics Committee at NIMHANS, Bengaluru. Written informed consent was taken from all the participants for both participation and publication. The privacy and confidentiality of the data was maintained Data was encrypted without any identification details of the participants for analysis. Apart from that, ethical standards such as confidentiality were maintained throughout the research process.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.