The central legal point established in the judgment is the obligation of insurance companies to provide non-discriminatory insurance coverage for mental illnesses as mandated by the Mental Healthcare Act, 2017.

JUDGMENT :

(Prathiba M. Singh, J.)

1. This hearing has been done through Video Conferencing.

2. Can mental illness be treated differently from physical illness for medical insurance purposes, is the question that arises in the present petition.

3. The petition raises an important issue relating to insurance coverage for mental illnesses and the provision of non-discrimination qua such illnesses as enshrined in Sections 21(1)(a) and 21(4) of the Mental Healthcare Act, 2017 (hereinafter, ‘MHA, 2017’).

4. The Petitioner in the present case regularly obtained health insurance policies from Respondent No. 1 - M/s National Insurance Company Limited (hereinafter, ‘NICL’), since 2016. The last policy was purchased by her on 29th May, 2020, named as ‘National Mediclaim Policy’ (hereinafter, ‘Healthcare Policy’). The said Healthcare Policy is valid for a period of one year 28th May, 2021. The sum insured was Rs. 3,95,000/-.

5. In June, 2020, the Petitioner developed a certain illness for which she obtained treatment from Sukoon Hospital, Gurugram. She was admitted in the hospital on 28th June, 2020 and was discharged on 28th July, 2020, after a month of treatment. The total expenses incurred by her was Rs. 5,54,636/- for the said period of hospitalization. She was diagnosed with Schizoaffective Disorder - a mental illness. The Petitioner then applied for reimbursement of the expenses incurred in her treatment, amounting to Rs. 5,54,636/-, from NICL in terms of Clause 1.1 of the Healthcare Policy. As per the Petitioner, she is entitled to reimbursement in terms of Clause 1.1 of the Healthcare Policy which provides for insurance policy coverage for medical expenses incurred for hospitalization. The clause reads as under:

“... The policy covers medical expenses for 30 (thirty) days of pre hospitalization, 60 (sixty) days of post hospitalization, 140+ day care procedures/surgeries, Ayurveda and homeopathy treatment, organ donor's medical expenses, maternity, hospital cash ambulance, air ambulance, medical emergency reunion, vaccination for children and medical second opinion.”

6. She, however, received a letter dated 1st September, 2020 from NICL rejecting her claim, relying upon Clause 4.10 of the Healthcare Policy. The said Clause specifies the exclusions for coverage, in respect of which the insurance company would not be liable to make payments under the Healthcare Policy. Clause 4.10 reads as under:

“4 - Exclusions: The company shall not be liable to make any payment under the policy, in respect of any expenses incurred in connection with or in respect of-

…

4.10 - Psychiatric disorder, intentional self-inflicted injury: Treatment for all psychiatric and psychosomatic disorders/diseases, intentional self inflicted injury, attempted suicide”

7. She then filed a complaint before the Insurance Ombudsman relying upon the provisions of MHA, 2017. The Insurance Ombudsman however, observed that the claim of the Petitioner would have to be settled in terms of the Clauses of the Healthcare Policy, and rejected the claim of the Petitioner.

8. The reliefs thus, prayed for in this petition are as under:

“a) Direct Respondent No.1 to reimburse the Mediclaim amount to Rs.5,54,363(Rupees Five Lakh Fifty-Four Thousand Six Hundred Thirty-Six Only)” while treating the Petitioner as it would have treated if mental illnesses were not excluded by the policy in compliance with Circular dated 16.08.2018 issued by the Respondent No.2.

b) Direct the Respondent No.2 to issue appropriate directions to Respondent No.1 to treat the Petitioner at par with the persons who purchased the National Mediclaim Policy after the amendment of the said policy to include coverage for mental illnesses.

c) Direct the Respondent No.1 to compensate for the mental harassment caused to the Petitioner due to the rejection of her claim.

d) Direct the Respondent No.1 to pay litigation cost to the Petitioner.”

9. Mr. Shahrukh Ejaz, ld. Counsel appearing for the Petitioner submits that the Petitioner is