Buy health insurance with OPD coverage for mental illness

 

Buy health insurance with OPD coverage for mental illness

The majority of mental ailments require outpatient treatment not hospitalization

The Insurance Regulatory and Development Authority of India (IRDAI) has taken a significant step toward ensuring equitable health insurance coverage for persons with mental illness. In a circular issued on February 27,2023, it mandated general and health insurers to provide coverage to individuals with mental illness, disabilities, and HIV/AIDS. The circular also urged insures to adopt a board approved underwriting policy that prevents discrimination against such individuals.

Challenges faced by the industry 

One major challenge the industry faces in covering such risks is lack of adequate data. According to Ashish Yadav head of products, Manipal Cigna Health Insurance, “We need more data on the incidence rate, how the segment behaves, and so on. This will enable the industry to come up with the right products for these segments and price them appropriately.”

The second challenges, according to him, which the industry grapples with in covering these segments, are non-disclosure.

What is covered?

The Mental Healthcare Act, 2017 had said every insurer shall provide medical insurance for the treatment of mental illness on the same basis as is available for the treatment of physical illness. In other words, insurers can’t discriminate between patients aliments.

“Earlier, people who had mental ailments were straightway denied coverage at the underwriting stage itself. But now they can buy a policy. If they have to serve a waiting period.

People suffering from mental aliments are currently underwritten. If accepted, they become part of the normal pool. The normal hospitalization products available in the market become available to them as well.”

Gaps in coverage

One issue with the coverage of mental illness is that underwriting standards vary from one insurer to another. Some insurers today have more stringent standards that lead to the exclusion of people having mental illness.

The other issue is that of exclusion.”While many policies say that they will cover mental illness, the wordings of a few still have mental illness as a permanent exclusion. After the new IRDAI circular, such exclusions should go away, “says Nayan Goswami, head sales & service, SANA Insurance Brokers.

Likely impact

The regulator’s latest circular will make it more difficult for insurers to deny coverage to those with mental aliments. The industry may be forced to adopt more uniform standards for accepting customers.

“After this circular, consumers will get greater clarity on the extent and scope of coverage for these conditions, what part will be cashless and what will be reimbursed, and finally, what will be executive director, policyBoss.com.

At present, insurers are extending coverage for these aliments by default across all their policies for those policyholder who don’t’ have a pre-existing condition. ”We expect to see product modification or new product launches for those with pre-existing conditions.” He says.

Insures not being able to deny coverage to those with mental aliments will have another positive fallout. “These patients will at least get coverage for many other ailments, which they may also suffer from, besides mental illness, “says Goswami.

For the mental ailment they already suffer from, they may have to serve a waiting period, though greater clarity is awaited on this (in policy wordings of insurers).

Needed, cover with OPD component 

About 80-90 Percent of the people who suffer from a mental illness require only outpatient care. Says S Prakash, managing director, Star Health and Allied Insurance: “Unless the insurance policy covers outpatient treatment – its pays for consultation and medicines- it won’t be able to help the community suffering from mental ailments. OPD care needs to be embedded in all routine health insurance covers.”

What you should do

A person suffering from a mental ailment should check the policy wording or the customer information sheet (CIS). “Download the policy wording and go through the entire section on exclusion to see if mental illnesses are excluded. Also check specifically whether the ailment you suffer from is exclusion.

Prakash suggests checking out three points: “one is there a waiting period? Two, is there a cover for OPD consultation allowed in all hospitals or only in a mental hospital?”

Singhal suggests opting for a policy whose waiting period is minimal.

Yadav emphasizes the importance of making proper disclosers about all pre-existing conditions at the time of purchase.

Finally, go for an insurer that has a high claim settlement ratio and check whether the network hospital of that insurer includes the ones you are likely to go to.

CHOOSE POLICY WITH SHORTER WAITING PERIOD:

According to regulations

 Insurers can’t discriminate between mental and physical ailments-both must be treated equally

The hospitalization covers offered by health and general insurers must cover mental illness also

Insurers, however , differ in their underwriting standards- some have more stringent standards that lead to the rejection of proposals of those having mental illness.

The bulk of patients having mental illnesses need outpatient treatment , so your hospitalization policy must have an adequate OPD cover

Waiting period will apply to pre-existing mental ailments also- choose policy with a shorter waiting period.

For More Details: Pooja Manoj Gupta, visit www.giia26.com
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