Insurance for mental illness: Government schemes must show the way

Mental Health Care Act, 2017 of India mandates that “Every person with mental illness shall be treated as equal to persons with physical illness in the provisions of all health care.” According to Section 21 (4), “Every insurer needs to make provisions for mental illness on the same basis as is available for treatment of physical illness.”[1] Almost 2 years have passed, but still there is no policy for mentally ill patients from insurers. Lack of mortality and morbidity data has been cited as one of the reasons for this delay.

To provide Universal Health Care, the government has been depending on delivery side and strengthening the infrastructure. The union government and state governments took a major step in this direction in 2007 when government-sponsored health insurance (HI) schemes were launched. These schemes included the Rashtriya Swasthya Bima Yojana, – now called Rashtriya Swasthya Suraksha Yojana, at the level of the union government. The schemes available at the state level included Rajiv Aarogyasri Scheme in Andhra Pradesh, Rajiv Gandhi Jeevandayee Arogya Yojna in Maharashtra, and Chief Minister's Comprehensive HI Scheme in Tamil Nadu.[2] In India, lakhs of families are being driven into poverty due to out-of-pocket (OOP) expenditure. The poor spend disproportionately large amounts to buy medicines. Health schemes have not been able to prevent this slide because major expenditure incurred is for outdoor treatment which is not covered in these schemes.[3]

For mental health, situation is bleaker as poverty is being considered one of the risk factors for mental disorder. Treatment of mental illness is done primarily on an outpatient basis. For most of the patients, burden of treatment is mainly met by OOP expenditure. Most of HI schemes do not cover mental illness and even disqualify persons with mental illness from deriving benefits for the treatment of physical illness. However, the National Mental Health Programme has strengthened the public infrastructure for mental heath delivery, and availability of free medication is now being ensured by most of the state governments.

Let us have a critical look into the current government-sponsored HI schemes. Ayushman Bharat, flagship scheme of Government of India, offers up to 5 lakhs insurance cover. For the first time, it offers cover for mental illness. It has 17 packages for mental health disorders, which also includes psychoactive substance use. It covers ECT, rTMS and most of the blood tests. However, insurance facilities are applicable to public sector hospitals only and not private hospitals whereas, for other medical disorders, it covers treatment in private hospitals also.[4] Some state governments have opted out of Ayushman Bharat citing their own health schemes.

Swasthya Sathi, HI scheme of the Government of West Bengal, offers cover up to 5 lakhs per annum per family, which includes up to 1.5 lakhs by insurance mode and rest by assurance mode. There is no cap on family size, and parents of both spouses are included. Unmarried daughters till the age of 21 years and all physically challenged dependent members of the family are covered.[5] Hence, it does not cover for mentally challenged. The scheme has no provision to cover mental illness. However, the state government provides free medicines and treatment through government hospitals.

Aarogyasri Health Scheme of Telangana State Government covers up to 1 year posttherapy for specified diseases and procedures. However, mental illness is not covered.[6]

Delhi Government's “Quality Health for all” scheme allows a patient of any one of the government hospitals to go to one of 67 private empanelled laboratories and hospitals for tests that cannot be performed in the government hospitals. Similarly, if a government hospital cannot give a surgery date to a patient within a month, the patient can go to any of the 44 private hospitals empanelled for this purpose. In both cases, the government will bear the cost. However, this scheme does not mention mental disorders.[7]

Biju Swasthya Kalyan Yojna of Odisha government offers free treatment in all government and empaneled hospitals for a sum of 5 lakhs for male members and 7 lakhs for female members. Reimbursement is done by the state government and not by insurance companies. It covers the cost of treatment of psychiatric disorders in government hospitals.[8]

These schemes must show the way forward. The government schemes must include the cost of OPD treatment and follow-up for mental disorders without discrimination as envisaged by MHCA, 2017. Apart from the coverage of treatment cost by insurance schemes, the infrastructure must be strengthened to provide treatment for all and close the treatment gap as far as possible. There is a need to generate public discourse and legal recourse to provide mental health equality and equity in health care by including mental health in government schemes to begin with and subsequently following-up with private sector.