In India, mental health is usually neglected, if not explicitly demeaned. Mental health should not be taboo in today's fast-paced, intensely competitive society since it is just as vital as physical health and ought to be treated with equal importance, if not more. Since the start of the COVID-19 epidemic, this mental health has received more attention than before.

Any kind of discrimination against people with mental disabilities or any disorder is prohibited by the "United Nations Convention on the Rights of People with Disabilities". Right back from the 1800s, mental health has been covered under various legislations in India. Recently, the "Mental Healthcare Bill, 2016"[1] was issued to bring a domestic legislation in accordance with the "United Nations Convention".

Finally, as a result of this, the "Mental Healthcare Act, 2017"[2] was passed by the parliament, and put to effect on May 29, 2018. Through a circular dated August 16, 2018, the "Insurance Regulatory and Development Authority of India" ("IRDAI") notified that with the implementation of the "Mental Healthcare Act, 2017", insurances are also required to cover mental disorders.

The insurance system of India is governed by the IRDAI. In order to prevent any sort of damage or loss for the policy holders, it is crucial/ to protect their interests by exercising supervisory authority over all insurance policies issued by the numerous insurers. The "Section 141 of the IRDAI Act, 1999"[3], safeguards policyholder's interest with regard to all types of policies, including the disposal of claims.

The IRDAI has a responsibility to "control" and "regulate" the "terms and conditions" of insurance policies. Therefore, it is the responsibility of IRDAI to make sure that the statutes passed for the benefit of policyholders are adequately implemented by insurers.

Through this project the author will cover the role of government in mental health developments in the recent years through the "Mental Healthcare Act 2017" and "Ayushmann Bharat Scheme", the current scenario of mental health insurance in India (public and private insurance companies), limitation of mental health insurance (includes global perspective) and landmark judgments on mental health insurance.

Health Insurance in India

Health insurance works as protection against potential medical or surgical costs. It is a contract in which a person or group of individuals prepay for health insurance by paying an amount known as the "premium". Depending on the kind of insurance policy, the insured is often either expected to pay for medical expenditures out of pocket and is later repaid by the insurer ("reimbursements"), or the insurer directly bears the costs and pays to the service provider (cashless claims).

The term service provider here includes, "clinic, hospital, doctor, laboratory, or any other facility" where the insured received healthcare services and for which the insured is supposed to a certain sum of money. Health insurance is exclusively offered for "hospitalization or inpatient care" in India whereas, "outpatient services", are not covered. "Private health insurance" and "public health insurance" are the two kinds of health insurance available in India.

1. Private Health Insurance
   Health insurance coverage are provided by several private firms. In this case, the person must pay a certain sum of money (referred to as the "premium") to a company that "pools" identical risks and covers them for medical expenditures on a regular basis (monthly, quarterly, or yearly). The key difference is that instead of being calculated as a percentage of the consumer's income, value of premiums are decided on the basis of evaluation of the "risk status of the consumer" and the scope of benefits offered.
    
2. Public Health Insurance
   These insurances are sponsored by the government and intended to offer health insurance coverage to particular groups, primarily the disadvantaged and vulnerable sections of the society. These insurance plans are funded by the tax and usually does not require payment of any premiums by the insured. The national and/or state governments in these situations bear the majority of the premium burden. Examples include the "Aam Aadmi Bima Yojana", "Employment State Insurance Scheme", "Rashtriya Swasthya Bima Yojana (RSBY)", and "Central Government Health Scheme."
    
3. Mediclaim Policy
   This first began in 1986. It pays for hospitalization costs incurred as a result of illness or accident sustained by the insured, even when the hospitalization takes place at home. It excludes outpatient medical care. The amount of premium paid by people is exempted from being included in "taxable income" to certain extent. Various insurance companies, including the general insurance companies, provide Mediclaim policy.

Mental healthcare insurance was not covered by the health insurance policies until the year 2019. Only after the COVID-19 pandemic mental health was given importance by the health insurance companies and was included in the terms of the policies. Mental illness is covered by public healthcare insurance firms "National Insurance Company Limited"[1] and "Oriental Insurance Company Limited",[2] which will only compensate the hospital or the insurer in the event of hospitalisation.

Any counselling, cognitive behavioural treatment, or psychotherapy that does not need hospitalisation is expressly stated to be excluded from their coverage in their policy terms. If at the time of policy registration, "Alzheimer's disease, dementia in Alzheimer's disease, and Parkinson's disease" are already present then they all permanently excluded by National Insurance Company Limited.

As of right now, "HDFC ERGO"[3] and "Aditya Birla Health Insurance"[4] both provide insurance coverage for mental health care, in addition to covering hospital charges. Mental diseases are covered under the complete indemnity plan of Manipal Cigna Health Insurance,[5] which only provides insurance in the event of hospitalisation. Treatment for mental disorders is covered by the "Max Bupa Health"[6] insurance company's "Health Recharge Insurance plan" up to the sum insured and, in some circumstances.

Role of Government

1. Mental Healthcare Act, 2017

   The act was passed by the Indian Government in the year 2017 and was implemented by may end of 2018. "Section 21(4) " of this act says, "Every insurer shall make provision for medical insurance for treatment of mental illness on the same basis as is available for treatment of physical illness."[1] The IRDAI issued a notification shortly after the MHCA, 2017 was passed, ordering all insurance companies to cover "mental illness" as part of medical health insurance. This change was really appreciated. But there are a few things to keep in mind: (a) unlike "physical illnesses", mental disorders lack a reliable method of "risk-based calculation." (b) Inpatient psychiatric treatment includes interventions that could not wholly fall under the heading of "medical interventions" (e.g., a "family therapy session", etc.). Prior to insurance covering costs for persons with mental disorders, these problems must be addressed.
    

2. Ayushman Bharat Yojana

   The Government of India's major initiative, Ayushman Bharat, was created to fulfil SDG 3 and attain "Universal Health Coverage". The "National Health Protection Scheme (NHPS), 2018" was passed under the "Ayushmann Bharat Yojana" of the government. The Indian government established the NHPS in 2018, which would replace the "Senior Citizen Health Insurance Scheme" and the "Rashtriya Swasthya Bima Yojana", two current centrally funded programmes. This "Ayushman Bharat Yojana" employs a dual approach. The first is to make "comprehensive primary care" easily available at a facility close to the people by enhancing and upgrading current facilities. Along with this it seeks to offer advice on yoga and other healthy living activities through health and wellness facilities around the nation.

Secondly, the "Pradhan Mantri Jan Arogya Yojana," which offers "cashless health insurance" coverage "up to Rs. 5 lakh per family (with no limit on family size) annually". The goal of this programme is to reach over 10 crore families nationwide, or around 40% of all Indians. This project is the greatest publicly sponsored health insurance programme in the history of the planet. A beneficiary insured by the programme may get "cashless benefits" from any public or private hospital impaneled in the nation because the program's benefits are transferable across borders. The government will choose the package pricing in advance, which will help to keep expenditures under control.

Landmark Cases:

1. Gaurav Kumar Bansal v. Union of India [1]

   Advocate Gaurav Bansal filed a PIL in the Apex court stating that the insurance companies are not following the provisions given under "section 21(4) of MHCA, 2017". A "three-judge" panel led by "Justice R. F. Nariman" stated that neither the IRDAI nor any insurance company had implemented any of the IRDAI's circulars. As a result, the court sent a notice to the relevant authorities, including the government and IRDAI, requesting that they carefully examine the situation and take the necessary steps to protect those who are suffering from mental illness.
    

2. Shikha Nischal v. National Insurance Company Limited & Anr.[2]

   A writ petition was filed by a lady whose application for health insurance claim to treat her mental illness was rejected. On May 29, 2020, the petitioner paid the National Insurance Company Limited (NIC) Rs. 3,95,000 for a National Mediclaim Policy with a one-year validity period. She was admitted to the hospital and incurred charges of Rs. 5,54,636 a few days later after getting diagnosed with "schizoaffective disorder".
   
   A policy exclusion provision that specified that no coverage would be offered in respect to "Psychiatric disorder, purposeful self-inflicted harm" was stated by NIC as a ground for rejecting her insurance claim. The petitioner then filed a complaint with the "insurance ombudsman" in this regard. The ombudsman gave a decision against the petitioner stating that since the terms of the policy specifically excluded "Psychiatric disorder" the insurance company is not bound to pay the claim. Aggrieved the orders of ombudsman the petitioner then filed this writ petition before the Delhi HC against such orders and against NIC for rejecting the claim.
   
   Ironically, NIC didn't contest the fact that "section 21(4) of the MHCA" mandates health insurance to cover mental diseases in the same way as "physical illnesses" throughout the court proceedings. Instead, NIC's argument was based on the "IRDAI's Guidelines on Product Filing in Health Insurance Business" (the "2016 Guidelines"), which state that an IRDAI-approved new product can only be commercially released within a maximum of six months before the insurance company must reapply for IRDAI approval.
   
   According to NIC, the IRDAI authorised its product covering mental diseases on March 27, 2020, and it was released within six months, on July 1, 2020. The petitioner was bound by the exclusionary provisions of her Mediclaim insurance since she had renewed it prior to the introduction of the new product. The Delhi High Court denied the National Insurance Commission's argument on the grounds that the "2016 Guidelines" cannot be read to delay the application of the 2017 Act, that had already been in effect since 2018. The MHCA, that came into effect at the time the petitioner bought the Mediclaim insurance and claimed reimbursement, therefore it had to be taken into consideration while interpreting the terms of the policy.
   
   It is interesting to note that shortly after the writ, the IRDAI ordered NIC "to pay the petitioner's claim and give a report on the status of other pending claims, in a letter to NIC that the latter had violated Section 21(4) of the MHCA." The Delhi HC held that the IRDAI had failed in performing its statutory responsibility to adequately regulate and ensure that "Section 21(4)" was followed by all insurance firms by failing to monitor the insurance companies in the current case.
   
   Finally, the Court decided that NIC was liable towards the petitioner's claim since it failed to comply with "Section 21(4) of the MHCA". The court ordered "NIC to pay the petitioner an extra 'Rs. 25,000 as litigation cost' since the petitioner had to resort to litigation in order for her claim to be honored, even though NIC had previously paid the petitioner's claim of 'Rs. 3,95,000' in accordance with the IRDAI's instructions." The bench further ruled that all insurance providers were required to implement "Section 21(4)" of the MHCA as of the day it took effect, suggesting that any health insurance plans issued after that date would need to cover mental illness regardless of any other conditions.
    

3. Subhash Khandelwal v. Max Bupa Health Insurance Company Limited [3]

   In this matter, the petitioner bought an insurance policy from "Max Bupa" which provided for an "assured sum of Rs. 35,00,000". The petitioner said that he was intimated about a clause in the policy reducing the sum promised to "INR 50,000" with certain additional restrictions that were in conflict with "Section 21 (4) of the MHCA" when he submitted his claim relating to mental illness.
   
   In its opening remarks, the Court highlighted that the contested policy does not fully cover and specifically excludes several types of mental disorders. This matter is still sub judice and the court has noted that this problem has to be taken into consideration because many individuals were impacted by these policies, and the court also served IRDA a notice to explain the criteria used to approve such policies.

Global Perspective

Developed countries which have a higher "Human Development Index (HDI)" have set up a well-organized system of mental healthcare insurance over the past few years and developing nations like India can take inspiration from there and develop such a system too.

1. USA
   Medicaid and Medicare are the two types of health insurance plans available in USA.[1] Medicare is based on age and Medicaid is based on income levels. Regardless of age, Americans with low income are eligible for Medicaid. "Inpatient and partial hospitalisation, residential care, outpatient mental health services, non-emergency transportation, case management, peer support services, psychiatric rehabilitation, crisis for children intervention, prescription drugs, long-term care, and early periodic screening, diagnosis, and treatment services" are all generally covered by Medicaid's mental health insurance plans. Additionally, "Assertive Community Treatment (ACT)", "Multisystemic Therapy", "In-Home and Family Support Services", and "Psychosocial Rehabilitation" can also be covered by Medicaid plans.
   
   A "state and federal" health insurance programme called the "Children's Health Insurance Program (CHIP)"[2] is available to "children under the age of 19" whose families make enough to qualify for Medicaid but not enough to afford private insurance. "Inpatient hospitalisation, outpatient mental health therapy, emergency care, and prescription medicines" are all covered under CHIP as mental health benefits.
   
   Only former military personnel are eligible for the government-run health insurance programmes called "TRICARE"[3] and "VA Health Care".[4] These programmes provide emergency care, prescription medicines, "inpatient hospitalisation for 30 to 45 days per admission or year, partial hospitalisation for 60 days per year, outpatient mental health treatments, and psychiatric residential therapy" for children and adolescents.
    
2. United Kingdom
   All UK citizens are covered by the publicly financed "National Health System (NHS)."[5] Although under NHS mental health treatments are free, in some circumstances a medical practitioner's recommendation is necessary. The following services are provided: "drug and alcohol services, eating disorder services, children's mental health services, and psychological treatment and counselling.
   
   It covers every facet of mental health care, such as advocacy, diagnosis, evaluation, rehabilitation, care, and support" for family members. The country spends about 10% of its GDP on healthcare. Only about 10.5% of people living in the UK choose private health insurance. When it comes to private insurance,[6] the majority of insurance companies define "mental health" in a way to cover all factors, including stress, postpartum depression, ADHD, eating disorders, addictions, ME, tiredness, and sadness and anxiety.
   
   Therefore, it is clear that several developed countries have already handled the issue of mental health with the utmost care. Several insurance policies have been developed by the government or private insurance companies to lessen the financial burden of treating chronic mental disorders. Additionally, they now include outpatient care and prescription medications, which is a good move in the fight against mental disorder.

Limitations:
India's insurers are more used to establishing policies that include hospitalization when an illness occurs. However, certain mental health issues are treated on outpatient basis, while others necessitate a few weeks to a few months of admission in the hospital.

Patients are required to continue taking their medications for a long period even after being discharged, which places a financial strain on the families. There may be more than one diagnosis for various mental diseases. Clarity is needed as to the "waiting period" post which specific mental disorders are covered.

In addition to drugs, regular therapy and counselling are also necessary for the treatment of mental problems, which can put families in financial difficulty. The premium value is usually decided by the insurance companies based on prior health conditions. Applying the same principles will be difficult in cases of mental illness. Some diseases, including schizophrenia, bipolar disorder, and recurrent depression, require a lifetime of treatment, demanding a continuous expense.

Conclusion
The MHCA of 2017 is a positive start toward transforming health insurance and keeps both physical and mental illness at par. Even now, there is a considerable disparity in mental health insurance coverage between developed and developing countries. The growth of the mental health insurance sector in India is hampered by a number of problems. India has a population of over 1-billion people, and more than 150 million of them need mental health treatments.

In India, the pre-COVID-19 condition was already dire, and this epidemic has added to the mental health issues. Therefore, COVID-19 has provided a chance to push insurance firms in India to provide adequate mental health coverage, which would significantly improve the care and treatment of people with mental illnesses.

Role of IRDA is of extreme importance with respect to the application of the guidelines which it has issued. There are several voids which are yet unanswered regarding the mental health conditions. The part of mental illness which shall be covered and which cannot be covered is to be determined.

There shall be a defined criterion for the determination of premium amount. Mental health insurances are yet to go a long way in order to develop a full-proof mechanism.

End-Notes:

1. https://www.nami.org/Your-Journey/Individuals-with-Mental-Illness/Understanding-Health-Insurance/Types-of-Health-Insurance last accessed on 2022 September 27
2. https://www.healthcare.gov/medicaid-chip/childrens-health-insurance-program last accessed on 2022 September 27.
3. https://tricare.mil/CoveredServices last accessed on 2022 September 27.
4. https://www.va.gov/VADODHEALTH/TRICARE last accessed on 2022 September 27.
5. https://www.nhs.uk/using-the-nhs/nhs-services/mental-health-services/ last accessed on 2022 September 27.
6. https://www.abi.org.uk/products-and-issues/choosing-the-right-insurance/health-insurance/mental-health/ last accessed on 2022 September 27.

Reference:

1. Gaurav Kumar Bansal v. Union of India and Another, Number W.P.(C) No. 000425/2020, Registered on 05-03-2020. Supreme Court of India; New Delhi, India; March 17, 2020.
2. Shikha Nischal v. National Insurance Company Ltd and Another, Number W.P.(C) No. 3190/2021, High Court of Delhi; New Delhi, India; April 19, 2021.
3. Subhash Khandelwal v. Max Bupa Health Insurance Company Limited, 2021 SCC OnLine Del 1751.
4. Mental Healthcare Act, 2017, � 21(4).
5. https://nationalinsurance.nic.co.in/en/health-insurance last accessed on 2022 September 26.
6. Ibid.
7. https://orientalinsurance.org.in/ last accessed on 2022 September 26.
8. https://www.adityabirlacapital.com/abc-of-money/does-health-insurance-cover-mental-illnesses/ last accessed on 2022 September 26.
9. https://www.manipalcigna.com/ last accessed on 2022 September 26.
10. https://www.maxbupa.com/ last accessed on 2022 September 26.
11. Mental Healthcare Bill, 2016.
12. Mental Healthcare Act, 2017.
13. Insurance Regulatory and Development Authority (IRDA) Act, 1999, � 141.