Health insurance for psychotherapy in India

INTRODUCTION Mental health care services form an integral component of Universal Health Coverage (UHC) to reduce the economic burden of the individual.[1] Many countries have taken steps toward achieving UHC by amending insurance policies for mental health service.[2] In this context, India has also taken imperative steps by the Mental Health Care Act (MHCA) 2017 in section 21,[3] providing insurance for mental illness by every insurer. MHCA defines mental illness in chapter 1 (sec 2) as a "substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs, but does not include mental retardation which is a condition of arrested or incomplete development of mind of a person, especially characterised by sub normality of intelligence". However, determination of mental illness will be as per the international standards as per MHCA sec 3.[3] Further, MHCA chapter 1 (sec 2) also defines mental health care as "analysis and diagnosis of a person's mental condition and treatment as well as care and rehabilitation of such person for his mental illness or suspected mental illness". Hence, as per the law, all the categories of mental illness and all treatment modalities for mental illness, including pharmacological, psychotherapy, and rehabilitation, shall have provision for medical insurance.[4] In this regard, the Insurance Regulatory and Development Authority of India (IRDAI) has made an obligation to all insurance companies to support treatment of mental illness.[5] Several insurance companies are adhering to the law, but exclusion clauses and altitudinal barriers of the insurance companies continue to exist in accessing psychotherapy. A considerable proportion of mental health services are in the exclusion clauses such as day care treatment, rehabilitation services, pre-existing mental illness, and outpatient department (OPD)-based treatment.[5,6] Insurers need to customize the policy considering the different treatment modalities for various mental illnesses. But insurers face obstacles in developing policies as they lack clarity on treatment modalities, such as reimbursement for medications, brain stimulation methods, psychotherapy, whether to include inpatient or outpatient therapy, number of sessions, and the duration of the treatment by considering episodic or chronic nature of the illness.[7,8] Thus, in this article, we aim to provide an outline to avail medical insurance for psychotherapy in India. METHODOLOGY OF THE REVIEW The authors searched for published articles in "Google scholar", and 'Pubmed' from 2018 to 2023. The electronic search on keywords such as "psychotherapy", "health insurance", "insurance policies", "mental health", mental illness", "psychosocial interventions", and "rehabilitation" found publications which were solely of reviews, commentaries, and perspectives. In addition to systematic review, we considered case reports and legal guidelines in writing this educational review. Current scenario of health insurance schemes for a person with mental illness According to Insurance Law (Amendment) Act 2015, section 2 (6c), "health insurance business" is defined as "means the effecting of contracts which provide for sickness benefits or medical, surgical or hospital expense benefits, whether in-patient or out-patient travel cover and personal accident cover."[9] In simple terms, health insurance covers the cost of medical services and materials used during inpatient or outpatient hospital expenses from unprecedented health issues. Insurance for mental health is very well formulated and executed in high-income countries with utmost care to reduce burden of mental illness.[2] Currently, subsidy schemes, social welfare insurance schemes of the government, and private insurance schemes cover 70% of the Indian population. However, ground reality shows a lesser proportion than the given report.[10] Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) in our country is one of the largest insurance coverage schemes in the world. It covers 40% of the Indian population with health coverage per year for a family up to INR 5 lakh rupees. It is a central government scheme providing a comprehensive package covering treatment costs for different categories of mental illness. The costs cover diagnostic assessments, counseling, and rehabilitation.[11] Along with Ayushman Bharat PMJAY, state insurance schemes also cover mental illness. For example, Karnataka state initiated Arogya Karnataka health insurance scheme for residents of Karnataka covering the cost of all mental and behavioral disorders[8] and Odisha state has Biju Swasthya Kalyan Yojna, which covers the treatment cost of mental illness in government hospitals. Niramaya Health Insurance schemes cover developmental disabilities up to INR 1 lakh under the PWD Act 1999.[5] Swavlamban Health Insurance Scheme provides insurance up to INR 2 lakh for all disabilities and mental illness; however, the scheme was stopped in 2017. All the central and state level schemes are restricted to the government sector. Some states have even excluded coverage for mental illness.[6,12] Private or federal health insurance plans in USA and publicly funded schemes in United Kingdom are covering expenses related to counseling, rehabilitation, crisis management, and family support.[8] Following IRDAI mandatory notifications, a few private health insurance companies have included insurance coverage for treatment for mental illness such as hospitalization, outpatient care, and counseling services,[13] but most of them have excluded treatment for alcohol and substance use disorder, neurodevelopmental disorders, suicide attempts, preventing care, psychological assessments, and outpatient base consultations.[5,8] There is a significant discrepancy in packages and exclusion clauses in public and private insurance companies for mental health care services. Reasons for such discrepancy are due to stigma, lack of data, and attitudes of insurers toward mental health, which has become a barrier to developing insurance packages. Even lack of clarity on the nature of mental health care services limited the coverage for insurance for mental health care services. There is a lack of clarity in characterization of psychotherapy, the number of sessions and duration, the accredited service providers, and costing of psychotherapy, and these pose challenges that have created a gap between insurers and patients.[14-16] Thus, it is important to describe the parameters of psychotherapy to avail the insurance. INSURANCE FOR PSYCHOTHERAPY Before we delve into the subjects, we need to define a few terms and key points to consider regarding health insurance coverage for psychotherapy in India. What is psychotherapy? There is evidence to support the role of psychotherapy as a part of mental health services. Psychotherapy and psychological counseling services not only reduce symptoms of mental disorder but also help in enhancing well-being.[17,18] The definition of psychotherapy according to Sharf (2012) is "Psychotherapy and counselling are interactions between a therapist/counsellor and one or more clients/patients. The purpose is to help the patient/client with problems that are related to disorders of thinking, emotional suffering, or problems of behaviour. Therapists use their knowledge of the theory of personality and psychotherapy or counselling to help the patient/client improve functioning. The therapist's approach to helping must be legally and ethically approved". According to American Psychiatric Association,[19] "Psychotherapy is a type of treatment that can help individuals experiencing a wide array of mental health conditions and emotional challenges. Psychotherapy can help not only alleviate symptoms but also, certain types of psychotherapies can help identify the psychological root causes of one's condition so a person can function better and have enhanced emotional well-being and healing" Thus, psychotherapy and counseling services for mental illness aim to reduce the symptoms of mental illness and enhance personality growth by improving functioning. There are various psychosocial theoretical models in psychotherapy. Based on the symptomatology of the patient and feasibility, the therapist provides psychotherapy to a given patient. What are the types of psychotherapy? Broadly, psychotherapy can be divided into two categories, individual and family psychotherapy. Individual psychotherapy focused on symptoms, psychological issues, and improving skill deficits of individual patients based on certain psychological models. Individual psychotherapy is a comprehensive treatment package that emphasizes emotional, behavioral, and social changes; it also includes remediations and rehabilitation such as vocational training, social skills training, and community-based interventions. Marital and family psychotherapy focuses on couple conflicts, removing distress within family members based on family therapy models [Table 1]. The emphasis of family intervention would be to reintegrate family cohesiveness and healthy relationships. Most of the time, patients require tailored psychotherapy which is 'eclectic' in nature, that is, a combination of various therapeutic principles and techniques. Hence, there should not be any restriction on the type of psychotherapy delivered to a particular patient and their family members. A few insurance companies can consider imposing restrictions on the number of therapy sessions allowed in a year and also capping the number of sessions per month based on the terms and conditions of the policy.[20,21]Table 1: Minimum requirement and types of psychotherapy that shall be considered for health insuranceWho can provide psychotherapy? Psychotherapy can be provided and reimbursed as per the following legislation: Mental health professionals under section 2 (1) of MHCA 2017 such as (g) clinical Psychologist recognized and licensed by the of Social Justice and Empowerment through the Rehabilitation Council of India (RCI) (1992).[22] (q) Mental health nurse, (r) mental health professionals, (x) psychiatric social worker, and (y) psychiatrist, who have been adequately trained in psychotherapy. Professionals under the domains of the National Commission for Allied and Healthcare Professions Act (2021) (NCAHPA)[23] such as professionals under behavioral health science who are adequately trained in therapy and accredited are eligible for providing psychotherapy and psychological counseling services. What are the ingredients of psychotherapy? Following psychiatric evaluation, diagnosis, and pharmacological treatment, patients are referred for psychotherapy. The stages of psychotherapy are divided into the initial, middle, and termination phases. In the initial phase, the focus is on assessment and diagnosis; the aim is to clarify and spend more time in insight into the patient. It includes an initial psychological assessment, intake session, commitment to therapy, and building therapeutic relationships. In the middle and process phases, we aim particular behaviors.[24] Further, consultants would decide the type of therapy for a given patient. Some patients may require booster sessions once in 3 to 6 months. The duration of the session varies; psychotherapy and psychological counseling vary with the number of sessions and duration of sessions.[25] The standard duration is therapy is 45 minutes to 60 minutes per session. For the inpatient, its daily bases of therapy till the discharge as defined by MHCA chapters 5 and 12. For the outpatient, therapy would be weekly for 6 months. Overall, it would be around 18–24 sessions inclusive of individuals and family therapies for 6 months. Insurance companies can consider imposing restrictions on the number of therapy sessions Allowed in a year or Number of sessions per inpatient admission or Number of sessions allowed per outpatient consultation in a year. IP- or OP-based psychotherapy is based on the severity of the illness and the type of psychotherapy. In the era of digital technology, online psychotherapy has also been covered by insurance companies aboard. Telemedicine guidelines also talk about counseling with regard to physical illness, similar to inperson consultation. What is the cost of psychotherapy? Currently, the COVID-19 pandemic led to a rise in demand, access, and caseload for psychosocial therapy. This impacted the cost of mental health services.[26] There is substantial variation in charges for therapy sessions. It is estimated that for mental illness, 770–880 INR is the treatment cost for outpatient service in India, inclusive of travel, medication, and clinical service by hospital.[27] Further, the average costs for therapy sessions are around 1000–1500 INR in Indian metros.[28] This includes digital versus inperson. Frequency of the sessions, the location (urban or rural), and the socioeconomic status of the patient also influence of the therapy costs. A government center such as National Institute of Mental Health and Neuro Science, Bangalore charges 100 INR to 200 INR per counseling session excluding psychological assessment. Given these variations, insurers can consider recommendations [Table 2] provided that can be covered under health insurance for psychotherapy; 500–1000 INR per session of psychotherapy or an appropriate costing for a course (15–20 sessions) may be reimbursed.Table 2: Components of psychotherapy that can be covered under health insuranceHow to claim insurance for psychotherapy in India? As per MHCA 2017, section 25, a patient has the right to information records; hence, a therapist needs to provide records of the therapy session as given in rule 6 as mentioned in Form B Format Mental health care rules, 2018 (Rights of Persons with Mental Illness). Insurers need to have only several sessions with a session reporting form signed by the therapist to release the fund. It is the responsibility of the patient to claim insurance using the record sheet. It needs to be at par with medical illness. However, the information to be disclosed to the insurance companies should be discussed with the patient and written informed consent to be taken, thus ensuring the right to confidentiality as per MHCA 2017 section 23. Insurance for crisis scenarios Mental health professionals are mandated to provide services for the following mental health crisis as per the Section 375 of Criminal (Amendment) act 2013, especially psychotherapy for victims of child sexual abuse, acid attack, and many insurance companies abroad deny psychotherapy services for exclusive attempted suicide or deliberate self-harm without any psychiatric diagnosis. However, such incidents are covered if they are presenting symptoms of a psychiatric diagnosis. Gray areas that need debate Though insurance for psychotherapy can be redefined with the above recommendations, there is incongruity in a few aspects which need wider debate at mental health professional and policy makers [Table 3]. Health insurance usually covers only one person per year in fixed (individual) insurance schemes. The sum insured in a fixed scheme can only be utilized for one person per admission. If insurance covers more than one family member who is a floater health insurance policy,[29] then the sum insured will cover all the family members. It is a big challenge for a family to care a person with mental illness for life long. Most of the time, families get tangled in the episodes of relapse and disabilities. They undergo emotional burnout and financial crisis; in such scenarios, providing supportive psychotherapy/counseling[30] to the family members of the person with mental illness should be included. Alternatively, the time exclusively spent with the family members in the context of the insured person's illness should be factored in fixing the charges.Table 3: Gray areas for wider debate for policy makersSituations like intellectual disabilities, cerebral palsy, down syndrome, and even severe mental illness with severe disability create familial issues and challenges in parenting. They need lifelong rehabilitation service, which imposes economic, social, and emotional burdens on the family. On February 2023, circulation of IRDAI mandates to include insurance coverage for persons with disability, mental illness disability under section 21 (4) of MHCA 2017, and RPWD Act 2016.[31] There is a need for limited tailor-made insurance coverage for continuum care of severe and lifelong disabilities.[32] There is a high prevalence of mild and subsyndromal cases with the risk of evolving into serious illnesses without treatment.[33] The treatment care is decided based on the severity of the illness, such as inpatient or outpatient treatment, type of medication, and psychotherapy. If the severity is mild or subsyndromal, it would create an issue in the level of treatment care and psychotherapy.[34] The subsyndromal diagnosis and mild cases can be determined as per ICD 11 and DSM 5, but MHCA section 3 only states the determination of mental illness based on national and international standard definitions. However, at this time, the central government of India has not notified whether to use ICD 11 or DSM 5. Thus, it creates vacuum in considering mild and subsyndromal illness in the inclusion clauses of the insurance policy. Providing psychotherapy for alcohol and/or drug dependence and those who attempted suicide is considered debatable. These are clinical conditions, and their management needs to come under the ambit of insurance coverage. To conclude, India passed the Mental Healthcare Act in 2017, which mandates that insurance providers to offer coverage for mental illnesses on par with physical illnesses. Some health insurance policies might have a waiting period before we can claim coverage for psychiatric illnesses. Some insurance plans might impose restrictions on the types of psychiatric treatments covered or the number of therapy sessions allowed in a year. Existing mental health conditions may be considered, although coverage for pre-existing conditions might be subject to specific terms. Some policies might have a waiting period before they cover pre-existing conditions. There is an urgent need to develop guidelines for including psychotherapy services under the ambit of health insurance [Table 4]. A consensus statement needs to be evolved from all the stakeholders including the insurance company representatives to iron out the gray areas of psychotherapy services and streamline the most needed mental health services in the community.