New Delhi: In a relief to patients with some mental illnesses, speech disorders, drug-related issues and those who are in need of artificial life support, the Insurance Regulatory and Development Authority of India (IRDAI) has come up with new guidelines that say that many of these issues can no longer be excluded from health insurance contracts.

However, people with HIV/AIDS, epilepsy, heart disease and a number of other common health ailments are to be “permanently excluded” from health insurance coverage.

This attempt at standardisation by IRDAI follows years of arbitrariness and variance across insurance contracts from different companies, which claim to cover some illness and not others. In order to streamline this, the IRDAI put together a working group in July 2018, and now has come up with the guidelines. The new guidelines standardise what kind of conditions can be excluded from health insurance contracts.

The new guidelines do four things: They list a number of health issues that cannot be excluded by insurance policies, and includes the standard language that should be used if there is an exclusion. They also list some existing diseases that can be excluded, and modern medical treatments that should be covered under insurance.

Health insurance policies can now no longer exclude the following:

• Treatment of mental illness, stress or psychological disorders and neurodegenerative disorders,
• Treatment of speech and language disorders such as stammering, dyslexia and any other behavioural and neurodevelopmental disorders, including in adults,
• Treatment that arises due a patient failing to follow medical advice,
• Injuries and illness associated with any hazardous activities (adventure sports will not be covered),
• Impairment of a person’s intellect due to drugs, stimulants or depressants, which are prescribed by a doctor,
• Artificial life support even if the treatment won’t result in the recovery of the patient to her previous state of health,
• Treatment for things related to puberty or menopause for women, and
• Treatments of age-related macular degeneration.

However there is still a substantial number of health conditions that are to be “permanently excluded” from health insurance policies, many of which are common:

• Epilepsy,
• HIV/AIDS,
• Hepatitis B,
• Heart ailment, congenital heart disease and valvular heart disease,
• Parkinson’s disease,
• Hearing loss, and
• Chronic liver disease and chronic kidney disease, pancreatic disease and inflammatory bowel disease.

Mental illness coverage is being delayed, HIV/AIDS is excluded

Although the guidelines say that mental illness is going to be covered by all health insurance policies, it is only for policies that are filed on or after October 1, 2019. Existing insurance policies will have to include mental illness only from October 1, 2020.

The Mental Healthcare Act was passed in 2017 and was enforced in 2018. So the IRDAI is delaying the implementation of this Act in insurance policies by at least three years.

Also on HIV/AIDS, parliament passed the HIV/AIDS Prevention and Control Act in 2017 and Section 3 of this Act says that “no person shall discriminate against the protected person on any ground including the denial of, or unfair treatment in the provision of insurance unless supported by actuarial studies”.

The Act clearly says that patients with HIV/AIDS are not supposed to be denied insurance coverage.

But on this, the IRDAI says that insurance companies are still bound by Section 3 of the Act and if they have actuarial studies that support the claim of denial of health insurance coverage to people with HIV/AIDS, then they can consider extending health insurance coverage to policy holders with HIV/AIDS.

In effect, this leaves people with HIV/AIDS at the mercy of insurance companies who can take a decision to allow or deny their medical coverage.