For decades, families of individuals with autism and related disorders have been fighting a silent battle, bearing not only the challenges of the condition itself but also the lack of support from any public health institutions. While many medical insurances are covering physical ailments and deficiencies, provisions for therapies that could help individuals with neurodevelopmental disorders, including autism and give them a chance to live a better life have remained scarce. In 2024, however, the Insurance Regulatory and Development Authority of India (IRDAI) released a circular bringing some major landmark changes to the autism and related health policies in India.
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What is ASD?
“Autism spectrum disorders (ASD) are a diverse group of conditions. They are characterised by some degree of difficulty with social interaction and communication. Other characteristics are atypical patterns of activities and behaviours, such as difficulty with transition from one activity to another, a focus on details and unusual reactions to sensations.” —WHO
Autism Spectrum Disorder was recognised as a disability in India under the Rights of Persons with Disabilities (RPwD) Act, 2016, ensuring certain rights and provisions for individuals dealing with autism and related disorders. They defined, “Autism spectrum disorder means a neuro-developmental condition typically appearing in the first three years of life that significantly affects a person’s ability to communicate, understand relationships and relate to others, and is frequently associated with unusual or stereotypical rituals or behaviours.”
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A Timeline of Events
For a long time, autism was not even considered a separate disability, often disregarded as children throwing tantrums due to a severe lack of awareness. Even the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995, the primary legislation that advocates for people with disabilities in India, didn’t recognise or specify the unique condition. It was only after the continuous efforts and protests of the Action for Autism or AFA, a non-profit educational and training programme that supports and advocates for individuals with autism, that led to its inclusion in the national trust bill, and changes began.
The first Indian legislation to specifically recognise autism and related spectrum disorders in India was the National Trust for Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities Act, 1999. They worked to set an institutional framework for schemes and programs promoting such individuals in areas of education, vocational training and healthcare. They also set out to register voluntary associations and organisations, along with their monitoring and evaluation. The Mental Healthcare Act, 2017, is another remarkable act that emphasises the rights of people with mental illnesses and other disabilities to access healthcare benefits in their daily lives.
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Recent Policy Changes
In the year 2024, the Insurance Regulatory and Development Authority of India (IRDAI) issued a circular that brought major changes to insurance policies for people with disabilities, neurodevelopmental problems and other mental health issues. Under this, private insurers can no longer deny or exclude individuals based on any neurodevelopmental (including autism) or other disorders.
Additionally, it reinforces the Rights of Persons with Disabilities Act, 2016 and the Mental Healthcare Act, 2017, mandating the provision of both offer and service of the health insurance policies in a fair and non-discriminatory manner to all individuals with autism, as persons with disabilities and those with mental illnesses. It actively works against their unfair treatment in the policy market. The 2024 circular doesn’t explicitly specify “autism” by name. However, it sets universal service guarantees and consumer protection that can be applied to all health policies, including those focusing on ASD related issues.
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Why This Reform Matters
For decades, disability treatment has been inaccessible for common people due to various factors ranging from a lack of information and awareness to its severely high costs. Autism spectrum disorder is becoming increasingly prevalent in India. A report from ETHealthWorld shows that it affects more than 18 million people. Since ASD is not a short-term “disease or problem” but potentially a lifetime condition, it becomes even more troublesome for people to meet its financial requirements.
Families of individuals with autism spectrum disorders have to pay large sums of money just for a basic diagnosis or assessment, while availing special education and other assistance and services remain only a dream. In such circumstances, the need for more neurodivergent inclusive healthcare is not just a necessity but also a right of all such individuals.
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What Insurance Now Covers
- Diagnostic Costs: All inpatient diagnostic and clinical assessments are typically payable under the scheme. OPD diagnostics, including rating scales, psychometry, are policy-specific.
- Hospitalisation: It is also covered if such admission is medically required, for instance, seizures and injuries associated with ASD.
- Occupational therapy: As an inpatient is payable, but OPD is excluded unless stated otherwise.
- Medicines: Inpatient medicines, as prescribed by neuro-psychologists or psychiatrists, are also covered under this.
- Speech and language therapy: Similar to occupational therapy, inpatient sessions for speech and language therapy are covered; however, OPD is policy-specific. Additionally, behavioural intervention is also covered in this scheme.
Read More: Applied Behavior Analysis: A Therapy for Children with Autism
What Insurance Still Excludes
- OPD: Unless it is specified, insurance plans don’t generally cover OPD. In case that they are, it is policy-specific and often only for a short while.
- Past Therapy: The claims do not apply to past therapy sessions. Only the ones that come after the release of the circular are added.
- Educational Services: Any form of particular long-term educational/ academic tools, including special school fees, training devices and other services, are not included in the payable list as they are not considered “medically required”.
- Therapy Caps: Therapy Caps refer to the annual limit put on the amount of service provided. Certain insurers may apply them for their services. Similar to educational services, insurance providers also exclude other aids, including consumables, unless the policy plans explicitly mention them.
Required Documents for the Claim
Whether for reimbursements or cashless claims, the following documents are to be submitted for a smooth claiming process:
- Prescription: The doctor’s prescription for the therapy or consultation is required to gather information regarding any medication or other assessment tools as directed.
- Diagnosis: A formal medical diagnosis report regarding the assessment of the individual with the disability. Typically, the use of DSM-5 or ICD-11 codes is preferred.
- Doctor’s information: They also often take into consideration the details of the practitioner involved in the diagnostic and further treatment process.
- Receipts: All the bills and payment receipts provided for the transaction give information about the monetary requirements, and also to avoid fraud.
- Disability Certificate: In certain circumstances, the child’s Disability Certificate can also be required for the claim.
Read More: Navigating through Autism: Alternative forms of communication
Steps to Avail the Services
As posed by the Indian Autism Centre, the following is the process:
- One should start by looking into their current or future policy and whether it involves provisions for autism and other related neurodevelopmental disorders. If not, they should make a good choice.
- Choosing the right policy is essential for availing the benefits. “What and how much is covered in policy?” are important questions that an individual should directly ask the insurers about. One should specifically look for policies regarding autism or neurospectrum disorders.
- One should specifically ask about the coverage of autism and related spectrum disorders in the policy to avail of the services.
- They should also look for whether the policy avails OPD, reimbursements and its policy for therapy caps, if any.
- They should ask for a written confirmation of the coverage as proof of the policy availed so that no future problems arise regarding the matter.
- In case a written confirmation is denied, individuals can seek support from the IRDAI, 2024 report.
- They should start collecting all the required documents for the coverage process.
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Areas For Improvement
Although the recent circular has brought about significant changes, authorities still have a lot of room for improvement. These are also the points that the carers of individuals with autism should look out for while buying a plan.
- The therapy caps and lack of OPD make the insurance and reimbursement efforts futile.
- Since not all plans and platforms cover autism insurance, people find it difficult to access.
- Even when insurance providers offer coverage, they exclude significant factors such as educational and other non-medical aids. Lack of provision for them makes it harder for autistic individuals to lead a normal, healthy life.
- Despite releasing the circular almost a year ago, authorities still face a significant lack of awareness and information among not only common people but also insurance providers.
- Due to the lack of proper implementation of the rule, the activation of the therapy benefits may take quite some time, possibly 1-2 years. This, along with no reimbursements for prior consultations and sessions, results in a severe lack of assistance for people dealing with autism spectrum disorders.
Conclusion
Healthcare for individuals on the autism spectrum has come a long way. From the disorder not even being listed as a separate condition to where it stands now hasn’t been an easy journey. The recent circular released by IRDAI came as a silver lining for families of individuals with autism spectrum disorders. It sheds light on the burdens of these families while also providing significant monetary relief and services for diagnostics, medicines, specific therapies and other hospital facilities.
People can avail these services by providing the necessary identity and diagnostic documents, such as prescriptions, diagnoses, and other certificates. While these changes have significantly improved Autism healthcare, several issues still need attention, including relief for OPD, therapy caps, educational support, and other non-medical services. Also, a certain amount of gap continues to exist regarding awareness and availability of information.
We must consider issues regarding ASD and healthcare because, if addressed properly, they can bring immense changes to the lives of people with autism spectrum disorder and their families. By providing access to these services, we can offer them a better lifestyle while also strengthening and encouraging them to move forward and create remarkable impacts on their lives and society at large. In the end, it is important to remember that inclusion is a right, not a favour. People can acquire it only through demanding accountability, continuing advocacy, and spreading awareness.
FAQs
1. What is the new Autism and healthcare insurance about?
The recent circular released by the IRDAI insurers aims to provide insurance for people with autism and other neurodevelopmental disorders without any unfair treatment, making it accessible for them.
2. What does the new insurance cover?
The new insurance covers various costs, either cashless or providing reimbursements, and includes diagnosis, medicines, different kinds of therapies and, if necessary, even hospitalisation.
3. What documents are required for the claim?
Insurance providers may require documents such as identity proof, diagnosis, bills and receipts, disability certificates, prescriptions, doctor’s information, and other specified proofs.
References +
autism-spectrum-disorders https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders
investment-for-future-planning https://www.hdfclife.com/insurance-knowledge-centre/investment-for-future-planning/living-with-au tism-in-india-is-asd-covered-under-health-insurance
Indian Autism Centre https://www.instagram.com/p/DM-Hdp5TFL2/?igsh=MXBzd2JlNnZ0MWx5bA== ● Insurance Regulatory and Development Authority of India. (2024, May 29). Master circular on health insurance business 2024 (Ref. No. IRDAI/HLT/CIR/PRO/84/5/2024)
