IMAGINE that someone you love has been struggling with a mental illness for a long time, but cannot afford to see a therapist in the private sector because it is too expensive.

One day, you learn that the person has attempted suicide and urgently requires professional intervention.

Yet even though she has purchased health insurance long before her illness began, she cannot use it to claim for a psychiatric evaluation because the medical plan specifically excludes “any attempted suicide or self-inflicted injury whether attempted or influenced while sane or insane.”

The scenario above is hypothetical, but in fact, it is a common reality. In Malaysia, health insurance policies do not cover the cost of psychiatric services.

This includes the cost of purchasing medication, consultations with a medical specialist (i.e. a psychiatrist) and psychological therapy sessions – in other words, the very health interventions that are crucial to helping those afflicted with mental health conditions to manage and recover from their illness.

Steep charges

How much does it cost to seek treatment for mental health in the private sector? Charges vary widely, depending on the provider and the type of service provided.

In most private centres offering psychological services, rates for a single psychotherapy session with a psychologist can typically range anywhere from RM250 to RM800. (This information was shared by a private psychiatric consultant who, for professional reasons, shall remain unnamed).

Staggering as it is, these figures merely represent the costs for one type of treatment. Patients with illnesses that require medication will incur even higher costs, since they need to pay for separate consultation visits to a psychiatrist and make purchases for drugs.  

(Unlike psychiatrists, who are medical specialists trained to diagnose and prescribe medication to treat mental illnesses, psychologists do not hold medical practising licenses and hence cannot prescribe medication).

As if the stigma of having a mental health diagnosis were not crippling enough, the fact that one would be charged an arm and a leg to see a private mental health provider is an even greater discouragement.

Cheaper options are available in public healthcare, yet anyone who has ever visited a public hospital would be familiar with the challenges of seeking service here – overcrowding and long waiting times being the major issues.

A recent online survey by the Malay Mail Online found that 26% of respondents reported excessive waits as the reason for stopping medical treatment at public clinics or hospitals in the past year. More than a third said they had waited an average of four hours to see a doctor. 

Leaving aside the reasons for the long wait times at public hospitals for a separate discussion, it is largely true that private healthcare offers patients better quality of service, in more comfortable settings.

But private treatment comes at a steep price and unfortunately, a majority if not all insurance companies do not include mental health as part of their covered medical benefits.

Thus, policyholders with mental health needs cannot claim against their policies to ease the burden of medical fees, even though they have paid squarely to invest in their health. This makes it more expensive for sufferers, even those that are insured, to seek help.

Why the exclusion

There are many possible reasons why insurers might hesitate to cover for mental health issues. First and foremost is the glaring lack of data needed to underwrite such policies. Since private insurance is a risk-pooling business, companies would need to balance their profitability against the likelihood of exposure to claims that could result in expensive pay outs.

Insurance companies rely on statistical data to evaluate risk, design policies and calculate premiums. However, in our country, there is still a lack of quantitative data on the burden of mental illness that would help facilitate this process.

Another possible, and no less dismaying, reason is that old misconceptions about mental illness still exist – those that see mental illnesses as not ‘real’ illnesses, but merely as character flaws or an inability to cope.

Stigma against mental health conditions is a troubling problem in our society. It would be unfair to pin the blame on any one party, as these are negative values and beliefs that society has collectively conditioned to be ‘norms’. Yet, left unchecked, such ‘norms’ eventually turn into actions of discrimination, which in turn leads to harmful outcomes.

Poorer groups are the hardest hit

Discrimination against mental illness in health insurance deters many from accessing help in private clinics and hospitals, but the hardest hit are poorer groups that simply cannot afford the expensive out-of-pocket charges.

Ironically, these are people who, through exposure to harsh and disadvantaged life conditions, may be especially vulnerable to developing mental illness. While those who have milder illnesses, or are in the early stages, may still be able to carry out their daily activities independently, foregoing treatment means risking worsened conditions in the long term.

Without proper treatment and support, there is a high risk that they will spiral downwards into especially debilitating and chronic conditions. Over time, they may lose the ability to hold down a stable job because of their symptoms (it does not help that workplace stigma is still an issue in our culture).

With loss of employment comes the loss of livelihood and a descent into a ‘vicious cycle’ that is extremely difficult to break. These people will face loss of self-direction, confidence and independence, and a reliance on caretakers. At the worst extremes, they may even be abandoned by their families and forced upon the streets for welfare support.

What needs to be done?

Certain transformations must take place in the insurance industry, in order to improve access to mental healthcare for all who are in need, especially disadvantaged groups.

Next year, the government has plans to implement a Voluntary Health Insurance Scheme (VHIS) through an agency under the Health Ministry. According to the Deputy Health Minister, premium for coverage under VHIS is pegged to be much lower compared to private health insurance. The government should include mental health coverage under this scheme to cater to the hardcore poor who cannot afford private health insurance.

At the same time, private employers should begin to offer mental healthcare treatment as part of their regular medical coverage for their employees. Doing so would set the precedent for private insurance companies to follow suit and offer private medical insurance that includes mental healthcare.

To achieve this, data is vital. Key stakeholders, such as the ministry of health, private research entities and NGOs must work together to gather statistics on mental illness in terms of healthcare, economic and social costs. That way, they will be able to put together a solid and convincing evidence-backed proposal to insurance companies to include mental health coverage in their policies.

But lobbying alone is not going to be enough if it falls on deaf ears. Ultimately, the insurance industry needs to realise that the mental illnesses are valid health conditions that rob people of their wellbeing and the ability to function successfully.

 With early detection and appropriate and timely treatment, there is a great chance that they will be able to regain a state of reasonable health and return to living with a sense of purpose and meaning.

Health insurance coverage for mental illness is a vital key to enable such interventions to take place. – December 24, 2017.

* Lim Su Lin is a Policy Analyst with Penang Institute in Kuala Lumpur. She graduated in 2013 with a degree in History from Cambridge University. Her research interests lie primarily in psychosocial health and wellbeing. She explores these in the context of making recommendations to improve social and development policies. The long-term goals of her work are to advocate for more equitable outcomes and reduced inequalities in society.

* This is the opinion of the writer or publication and does not necessarily represent the views of The Malaysian Insight. Article may be edited for brevity and clarity.