Buy an adequate OPD cover to take care of mental health treatment

Most of these ailments are treated on outpatient basis, so just a hospitalisation cover won't suffice

A recent survey by Deloitte found that poor mental health among employees costs Indian employers around $14 billion (Rs 1.1 trillion) a year on account of absenteeism, lower productivity, and attrition. While workplace-related stresses were already contributing to a high incidence of mental ailments, the pandemic exacerbated the problem by restricting social interactions and creating financial challenges (loss of job, business, etc).

“With increasing awareness, however, the social stigma surrounding mental health issues has reduced since the pandemic, and people have become more open to seeking professional help,” says Mayank Bathwal, chief executive officer, Aditya Birla Health Insurance.

Is mental health covered?

The Mental Healthcare Act was passed in 2017. “Following the passing of the Act, the Insurance Regulatory and Development Authority of India (IRDAI) also mandated insurers not to discriminate between mental and physical ailments and to cover the former just as they cover the latter,” says Bhabatosh Mishra, director-underwriting, products and claims, Niva Bupa Health Insurance.

Hence, retail comprehensive health insurance policies cover mental ailments, provided the patient is hospitalised for at least 24 hours.

OPD treatment required

The bulk of mental ailments (depression, anxiety, etc) require treatment on an outpatient department (OPD) basis. “About 90 per cent of such patients can be treated in OPD,” says S Prakash, managing director, Star Health and Allied Insurance. But the majority of health insurance policies, barring a few newer ones, offer only hospitalisation coverage.

The OPD covers that are available also have a number of issues. “Currently, the premium charged for OPD coverage vis-à-vis the sum insured offered is relatively high,” says Nayan Goswami, head-group business and sales & service, SANA Insurance Brokers.

Many wellness platforms offer counselling sessions. But these are offered by certified counsellors. An OPD cover may not compensate you for sessions not conducted by a certified doctor.

Moreover, the charge per counselling session could be higher than the per session amount reimbursed by the OPD cover (though some policies don’t have limits).

Will you get coverage?

Just because it is mandatory for insurers to provide coverage for mental conditions doesn’t mean they will cover every person. Whether or not a person gets a cover depends on the insurer’s underwriting. Some who already have a severe condition, or an ailment that is progressing rapidly, could be denied coverage.

“All pre-existing diseases (PEDs) must be disclosed, after which the insurer does the underwriting. It could then either accept or decline the proposal. If it accepts, it could do so with a permanent exclusion (meaning not cover the pre-existing disease). Or it may cover the pre-existing ailment after a waiting period,” says Amit Chhabra, head-health & travel insurance, Policybazaar.com. The waiting period can vary from two to four years.

Key exclusions

Most policies exclude congenital problems. Mental retardation, arrested or incomplete development of a person’s mind, and subnormal intelligence are permanent exclusions.

Check for sub-limits

Some policies, like HDFC’s My Health Suraksha, Niva Bupa Health Premia, and ManipalCigna Lifetime Health, explicitly mention in their policy documents the mental ailments they will cover. Many popular policies don’t. “In policies that don’t explicitly mention they will cover mental ailments, it has to be deemed they will do so because of the regulator’s circular. But it is advisable to opt for policies that explicitly mention they will cover mental ailments up to their sum insured without any sub-limits,” says Goswami.

OPD cover is crucial

Buy a policy with an OPD component. “Having adequate OPD coverage is crucial because mental illnesses require prolonged consultations,” says Chhabra.

Experts suggest an OPD coverage of minimum Rs 10,000, though Rs 25,000-50,000 is a safer limit. While purchasing check that the OPD component doesn’t have any sub-limit or exclusions for mental health treatment.

An OPD policy covers consultation, pharmacy and diagnostics. “Check whether there are limits on each of these components. In case of a mental ailment, the spend on consultancy and pharmacy will be considerable,” says Mishra.

Adds Goswami: “Policies may have unlimited coverage for general practitioners, but may have limits on consultations with specialists. Check that. Also, check the limit on the amount compensated per consultation.”