World Autism Awareness Day 2024 — Scope of insurance and coverage available for the disease

As World Autism Awareness Day approaches on April 2, 2024, it’s crucial to shine a light on the scope of insurance coverage available for individuals living with autism spectrum disorder (ASD). Autism affects millions of children globally, with varying degrees of severity and unique challenges for each individual.

ASD is a neurodevelopmental disorder characterized by challenges in social interaction, communication, and behavior. Individuals with autism may have difficulty understanding social cues, expressing themselves verbally or nonverbally, and may engage in repetitive behaviors or have narrow interests. Autism manifests differently in each person, ranging from mild to severe, and often coexists with other conditions.

Detecting and diagnosing Autism early is vital for offering timely intervention and support, which significantly enhances the long-term outcomes for affected children. However, accessing these vital services can be financially burdensome for many families.

The prevalence of Autism in India has been progressively rising. According to a 2021 research article in the Indian Journal of Paediatrics, the approximate occurrence rate of Autism among children globally is around 1 in 68. The condition has affected boys more commonly than girls, with a gender ratio of approximately 3:1 in favor of males.

According to a 2019 media report, Chitra Iyer, the founder of the Forum for Autism in India, indicated that the monthly expenses for caring for a child with autism can vary from Rs 6,000 to Rs 25,000. At present, only a limited number of health insurance policies in India offer coverage for expenses related to Autism. The Indian government extends the Niramaya Health Insurance scheme to individuals with autism, as per the National Trust Act of 1999. Furthermore, Star Special Care Insurance, a private insurer, offers a specialized insurance plan tailored for autism. Except for Star Special Care Insurance, other private insurance companies do not offer dedicated insurance plans for autism. Instead, autism is generally covered under the mental health issues category by all insurers.

Niramaya Health Insurance :

The "Niramaya" health insurance scheme aims to provide financial coverage for individuals with autism. Under this scheme, the Indian government offers a maximum sum assured of Rs. 1 lakh on a reimbursement basis only to support the treatment and care of children affected by autism.

The scheme covers facilities for OPD treatment including medicines, pathology, diagnostic tests, etc, medical check-ups for non-ailing disabled, dental preventive dentistry, surgery to prevent further aggravation of disability, non-surgical/ hospitalization, corrective surgeries for existing disability including congenital disability, ongoing therapies to reduce the impact of disability and disability-related complications, alternative medicine and transportation costs.

This insurance scheme is accessible nationwide without the need for a pre-insurance medical examination. It aims to offer extensive coverage that includes a uniform premium for all age groups. It provides the same coverage regardless of the disability type as defined under the National Trust Act. All individuals with disabilities covered by the National Trust Act, who possess a valid disability certificate, are eligible and can be included in this scheme.

1)Eligibility and Enrolment:

All Persons with Disabilities (PwDs) possessing a valid disability certificate for at least one of the disabilities outlined in the National Trust Act, 1999, are eligible to apply for the scheme. This includes individuals with a UDID Card Number or Enrol Number under UDID, provided they have a Person with Disability Certificate.

The enrolment under the Niramaya scheme can be done by visiting the nearest Registered Organisation(RO). The enrolment process is carried out at an RO and involves filling out an online application/proposal form, uploading documents for verification and payment of the fees as per the PwD category. On successful enrolment and approval, Health ID No. /card will be issued to the beneficiary. The renewal of the scheme can be done both by visiting the Registered Organisations or Online.

2)Process of Claim Settlement:

The settlement of claims is on a reimbursement basis only, under the Niramaya scheme one has to submit a prescribed Claim Form along with relevant vouchers/bills, etc. within 30 days of treatment or discharge from the hospital. The claim form can be downloaded from the website and sent to the Third Party Administrator, authorized by the Insurance Company.

Should the RO or the PwD encounter any problems related to the scheme, they have the option to report the issue through the Grievance Redressal System available on the National Trust website, or they can reach out directly to the concerned official or the CEO of the National Trust via the office phone number. The dedicated helpline for claims: 040-68178547.

Star Special Care:

Star Special Care is a policy that provides indemnity cover for people aged between 3 and 25 years who are diagnosed with ASD. This policy provides a Sum Insured of Rs. 3,00,000/- with a starting premium of INR 447 per month. Under this policy, a pre-insurance medical screening is not mandatory. However, submission of all previous medical records is necessary. The waiting period for pre-existing disease coverage in the Star Special Care policy is 4 years for children with autism. This policy also offers the following.

1)Cashless Hospitalization:

Children covered by the insurance can access cashless hospitalization services at over 12,000 network hospitals affiliated with Star Health & Allied Insurance Company.

2)Specialized Cover:

This policy covers expenses for outpatient specialized treatments like Behavioural Therapy, Speech Therapy, Physiotherapy, and Occupational Therapy.

3)In-patient Hospitalization Expenses:

This policy includes hospitalization costs covering room charges, nursing charges, and boarding expenses, up to Rs 5,000 per day. Additionally, it covers fees levied by surgeons, doctors, anesthetists, and specialists, as well as expenses for blood, oxygen, anesthesia, surgical appliances, operation theater charges, medicines, and drugs.

4)Emergency Ambulance Cover:

This policy provides coverage for ambulance charges, up to Rs 750 per hospitalization and up to Rs 1500 for the entire policy term.

5)Post-hospitalization Expenses:

The policy includes post-hospitalization expenses, which amount to 7% of the hospitalization cost or actual charges, for a duration of up to 60 days following discharge.

6)Tax Benefits:

The premium paid under this policy is eligible for tax deductions under Section 80D of the Income Tax Act 1961.

In conclusion, while progress has been made in expanding insurance coverage for autism-related services, there is still much work to be done to ensure that individuals with ASD receive the care and support they need to thrive. On World Autism Awareness Day and beyond, let us continue to work towards a future where all individuals, regardless of their neurodevelopmental differences, have access to the resources and opportunities they need to reach their full potential.