Mental Health Exclusion

GravatarI am in Australia and feel very fortunate when it comes to public health services. When we opt for Private Health Insurance in Australia, it is so that we can get additional cash back on selected services and also more easily afford non-Government medical practitioners and hospitals. Private Health Insurance is also priced around age and services you would like covered, not around your medical history or risk (even though there are eligibility periods for certain claims). But you don’t need Health Insurance to get good medical care in Australia, as is the case in other countries. For that I am grateful.

But that is not what I wanted to talk about here. I just stated it to clarify what Insurance I am referring to in this post. I am referring to other kinds of insurances and the Mental Health Exclusions that are so broadly and freely applied. Policies like Life Insurance, Income Protection Insurance and Total & Permanent Disability (TPD) Insurance. Insurances that people take to ensure they and their loved ones are financially cared for and covered in the event of fatal or debilitating accidents/illnesses.

I have Life and Income Protection Insurance that costs me over $150 per month. The purpose is to ensure my family are protected and provided for financially in the event I can no longer work or provide for them. Yet, because I have anxiety and depression listed in my medical history, my policy includes a “Mental Health Exclusion”. I took this policy out in 2010 and at the time did not question the exclusion. To be honest, at the time I felt a little embarrassed talking to the agent about my anxiety and depression – stupid male pride – so didn’t question it when they applied the exclusion. However I am now more confident talking about it and phoned them today to ask what my exclusion means and request it be reviewed. They are going to get back to me 🙂

I was told in 2010 (when I took out the policy) that if I did not see a doctor for any mental health related reasons in the next few years I may be able to have the exclusion removed. So, even though I have had some difficult times these past years, I have avoided talking to my doctor directly about any anxiety or bouts of depression I have experienced. My doctor who knows my history frequently looks me in the eyes when I see her for other medical appointments and asks very deliberately, “So how are You?” … to which I always reply, “Yeah, you know, good. I’m doing well” … or words to that effect. I dare not say how I have been feeling or recounting a bad experience in case she records it in her notes on the computer – thereby extending the period of my exclusion.

Beyond Blue did some research earlier this year and found that Insurance Companies in Australia can legally discriminate against a person with a disability if their discrimination is reasonable with regards to actuarial or statistical data. If there is no such data, insurers can instead rely on ‘other relevant factors’ particular to the individual.

However what was also clear to Beyond Blue is that the data being used by Insurance Companies is questionable and lacks transparency. Some insurance companies even apply exclusions to people who have not been diagnosed with a Mental Illness, but have a record of visiting a counselor or psychologist. Worse than this, data is not freely or easily accessible regarding the actuarial judgments made by insurance companies in order to determine if it is in fact reasonable for them to apply such broad exclusions.

In my case, because I had anxiety and depression, I am excluded from ANY Mental Health claim at all.


Let’s apply the same principle to physical ailments. If I had a broken arm in my medical history, I should receive a “Broken Bone Exclusion” for every bone in my body – right?

I also have a friend who has an exclusion on his left knee because of a past sports injury. Interesting that he didn’t get a “Joint Exclusion” for every joint in his body.

There are two things that don’t sit right with me here:

  1. Big Insurance Companies Stigmatizing Mental Illness: They do this by bundling ALL mental illness into one broad category. How can they exclude all mental health claims because of the existence of one particular kind of illness – when the same approach is not taken with physical health?
  2. Big Insurance Companies Discouraging Mental Health Treatment: The agent I spoke to encouraged me to aim for a period of being symptom and treatment free in order for the exclusion to be lifted … “Just make sure you don’t discuss anything more with your doctor for a few years and I am sure we can remove the exclusion.” What sort of advice is that? Seeking help is hard enough, without having an Insurance Company encouraging me not to do so.

Based on the research and reading I have done today, I have options and so does my Insurance Company. It seems there is no real standard to how these exclusions are applied or judgments are made. Therefore, when they call back in the next few days, I will be asking them to remove or narrow the exclusion … or I will find an Insurance Company that will.

I know each country has different healthcare systems and structures, but I am certain I am not alone in my experience with broad and ambiguous Mental Health Exclusions.

What has been your experience?

Some additional reading from Beyond Blue:

2011 Report of Mental Health Discrimination and Insurance

2013 Article regarding joint project with the Mental Health Council of Australia

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21 thoughts on “Mental Health Exclusion

  1. Your Exclusions sound a lot like “pre-existing conditions” in US insurance parlance. Except prior to the recent Affordable Care Act (Obamacare), insurers could completely deny any coverage at all, in addition to exclusions, and pre-existing conditions basically never, ever go away, even if you’ve fully recovered. That pretty much applied to all types of insurance.

    In mental health care, this means that doctors often give a more generic Dx that is less directly stigmatized but still eligible for insurance coverage, e.g. Mood Disorder NOS instead of Bipolar. Except that sometimes insurance still denies some services unless you have the “right” Dx – so one of my providers changed my Dx to Borderline Personality Disorder (without consulting me) so that I could continue DBT. Had they consulted me, I would have paid out of pocket to complete DBT rather than allowing Borderline to get on my “permanent record” but it’s there now, although no one believes it’s remotely accurate and it could become a problem for me in the future for life and disability insurances. And guess what? I can’t do anything about it.

    Even though most people didn’t get what they really wanted out of the Obamacare legislation, I think it’s major progress that I can no longer be categorically denied health insurance because I’ve had mental health treatment in the past. Maybe someday that will be extended to other forms of personal insurance, but I’m not holding my breath.

    • Thanks for that. I wasn’t completely sure what obamacare was all about.
      Private health insurance in Australia is already pretty good and has been good for some time when it comes to exclusions and preexisting conditions – reasonable and not discriminatory. And besides, no one ‘needs’ private health insurance here to get good care. The public health system is essentially free. When it comes to mental illnesses your GP can often assist you and the government will pay for a number of free psychologist appointments.
      It is with other personal insurances (life, income protection, disability, etc.) that the discrimination exists. Whilst my friend can have a preexisting knee injury that gets excluded forever – it is only his knee that is excluded.
      Because I have had anxiety and depression, I am excluded forever for any mental health claims – no matter what the diagnosis. That is the type of exclusion I was referring to … which is very different to how physical injuries or physical illnesses are handled here with other personal insurances.
      There had been a lot of improvements in recent years to these discriminatory broad exclusions, but insurance companies can still apply them with no transparency in their decision making and little accountability. So … at the moment it is best to shop around and find an insurer that wants your money and is prepared to not have exclusions or at least make sure the exclusion is specific to only your illness (like a typical preexisting condition should be handled) and not ALL types of mental illness.

  2. i agree with dee-dee that your exclusions sound much like our pre-existing conditions. if you are on private insurance here, that either you buy yourself or your employer offers to you at a lower cost, you cannot be treated for anything already in your record as having be diagnosed or treated in the past. i was lucky enough to have never been to the doc for anything more than a cold when i first was diagnosed, so my husbands’ insurance through work was more than happy to pay for anything i needed since i had no pre-existings. there are two forms of public insurance (not referring to obamacare) here–medicaid (for those who are poor enough) and medicare (for those old enough or disabled) and they do not have any pre-existing rules and will cover anything your doctor orders, including referrals to other docs and those docs’ orders.

    so in my experience, i was very lucky to have had a clean slate when i first became diagnosed with bipolar, and a few years later when i was legally determined to be disabled, i was also lucky to be able to use both medicare (for elderly and disabled) and also for medicaid (for low income), and not only do they both pay for anything my doc orders, but together they pay 100%, including copays, deductibles and premiums.

    and now that ‘obamacare’ has started, everyone who is not already on insurance offered by their employer, or private insurance they pay for all on their own, or on either or both medicare and medicaid, will be able to get coverage that is reasonably priced and is now legally required to cover any treatment or diagnosis even if it is pre-existing. so hopefully, pre-existing conditions, or ‘exclusions’ will be a thing of the past here in the relatively near future.

    • Okay. That is interesting. I think obamacare has brought your health system closer to where we are here in Australia already. But I am sure we are way ahead, since healthcare is already essentially free for all (or at least heavily subsidized through medicare). Private health insurance here essentially helps you with covering a larger percentage of your out-of-pocket expenses and accessing any optional medical services.
      We also have both public and private hospitals in Australia. Anyone and everyone can go to a public hospital for (essentially) free treatment. But if you have private health insurance you can afford to go to one of the private hospitals and in many cases avoid long waiting lists that can often occur with public (free) hospital treatment. Plus the private hospitals also have more bells and whistles when you stay in them – kind of like 5 star compared to 3 star when it comes to the accommodation side of things.

      Appreciated you explaining more about how the US system works. I understand it better now … it sounds very different to here and I belive in much more need of improvement.

      No matter where you live in the world, medical assistance and care should be a basic human right. Not something only the rich can afford or people with no previous illness can access. I don’t care how utopian that sounds 😉

      • we should be striving for utopia especially when it comes to healthcare, as i, like you, believe it should be an unalienable right simply for being a human being. and yes, obamacare does actually bring us more toward the european, canadian, and australian model. and yes, it does still have a long way to go before it becomes an essentially free system. i believe obamacare is probably moving in that direction, as he has said he wants to take the medicare coverage (offered by gov’t to elderly and disabled, and its costs are dependent on your income level, and it can be augmented by medicaid, coverage for the poor provided by the gov’t) he wants to expand medicare for the entire population and have people be able to choose it or any of the private insurance but all at rate based on your income. this would lead to everyone having mostly complete coverage, and still have a choice of providers and pay the same no matter which provider is chosen, if you must pay at all.

        • That does sound like good progress and I hope his future plans are realized, would be a pretty equitable scheme the way you describe it.
          One of the frustrating thing here in Australia with our system is that whenever the Govt increases its subsidizing of medical expenses or private health fund fees, the service providers (whether practitioners or insurance companies) often increase their charges so that we – the consumer – are always out of pocket by the same amount.
          Well intended Governments will always find it challenging to control big businesses such as Pharmaceutical and Insurance Companies – complaints aside, it is nice to live in countries that give it a try 🙂
          All the best with more accessible care!

  3. That really sucks. I know here a lot of mental health things are just covered under most policies, but until now because of our new healthcare law companies could just flat out deny you based on your records for various pre-existing conditions, which is just like what you have said here. For the longest time I have been without health coverage due to the cost and pre-existing conditions. I may finally now be able to get it. My heart goes out to you. sighs..

    • Yeah. It is actually not so bad here in Australia. What I am mostly talking about is the kind of additional personal insurance that I am fortunate enough to be able to afford. It just disappointed me to realize the discriminatory way in which these policies handled mental illness – as though it was a “no go” zone, or poisoned chalice in the hands of a potential policy holder.
      Baby steps I suppose when it comes to healthcare and change for awareness about mental illness. Sounds like the US has made some progress, but there is still plenty more to be done (even here in Oz).

  4. Several things to clarify in the U.S. system. Medicare and Medicaid are only useful insofar as you can find a healthcare practioner who will accept them — and that number is disturbingly few due to the ridiculous Sustainable Growth Rate issue (you don’t even want me to get into that), pay-for-performance (another thing you don’t want me to go on about) and a few other issues, all of which add up to good doctors getting paid next to nothing by the government. I take this maybe more personally than I should because mine is one of them. The number of primary care doctors has dropped (and is continuing to drop) dramatically, to the point where the average wait time to see a PCP (GP) is 49 days — and that’s with private insurance as well. The money is in the procedures done in specialty work, and with students graduating med school with ridiculous amounts of debt, they’re going to go where the money is. Psychiatrists — good psychiatrists — are even fewer and farther between, especially those who take Medicare/Medicaid.

    Obamacare has finally passed, and that’s a wonderful thing. But in a couple of years we’ll have a new president, one who will likely not be in line with Mr. Obama’s policies to a greater or lesser degree, and one who will spend his first term in office making sure he doesn’t do anything to threaten his reelection. That’s something even now the average citizen in the country doesn’t seem to “get” — that the last three years of a second-term president are really the time when he can actually get down to real and lasting change. Then again, maybe I’m cynical, or maybe my extensive poly-sci background just gives me a more realistic understanding.

    Sorry to be a grump and get off topic. It has not been a good 24 hours where I live (to understate things vastly), and my mind is apt to wander.

    • hmmm….i am on Medicare, as i am disabled, and also on Medicaid, as my secondary insurance, as since I am disabled, i am quite poor. I have all my services covered 100% between the two, and I have never encountered a doctor i couldn’t go to. also, i don’t need referrals to see a specialist, and i can get any doctor appointment right away (within 1 week) for mental health, for physical health, for specialists, for things like pain management, nephrologists, surgeons, procedures and labs, etc. and i have only encountered docs i didn’t like once or twice in over 6 years. being on medicare and medicaid both is better insurance than when i had my husbands’ insurance when he was working for state government and we had blue cross/blue shield (and government insurance is one of the best offered). and oh, i have a soc background, with focus in social services and poverty. also, i have experienced using medicare and medicaid in more than one state, in more than one region of the us, and my experience as described above is the same in all areas i used these coverages. also, if you only have medicare, it will cover approximately 80% and if you only have medicaid, it will cover 100%, with possibly some copays for providers and for meds–but they are nominal. if you have both, you pay 0%.

      • Really? How interesting. Of course I’m basing my statements on discussions with various doctors in the Denver Metro region, as well as information I get from the AMA and APA. I have excellent private insurance, though being on disability I am eligible for Medicaid — there seems to be some confusion here, because Medicaid is what I became eligible for when I was approved disability, not Medicare. In any case I have had extensive discussions with doctors about what they will and will not accept insurance-wise, and when I do have to go on Medicaid in a little over a year, the only doctor I will continue to be able to see is my primary — who along with his practice partner is the only physician I have found accepting it in the myriad number of doctors I have been to see in the past years. Certainly my psychiatrist doesn’t accept it (nor did my past psychiatrist), but that is their privilege when demand so far outstrips supply — very few psychiatrists I have contacted recently are accommodating any new patients, health insurance completely notwithstanding — and when what Medicare and Medicaid pay are substantially less then most privatized insurance. And I’m not talking about what they cover, I’m talking about the actual dollar amounts physicians are reimbursed based on negotiated rates with insurers. My primary actually grew overloaded with the number of Medicare/Medicaid patients he was treating, because at the time he was the only PCP in the area accepting it. And you need to keep in mind that 49 days is an average, given out in the last couple of months by the AMA itself, which means it varies based on doctor to patient ratio in any given area. But when I had to switch primaries temporarily this year, I waited well over a month before I got in to see my new doctor for the first time — this is what the 49 day figure is taken from: average wait time for a new primary care doctor. It does not apply to specialties, nor does it apply if you are an established patient.

        • medicaid is by definition income based, and has other restrictions. it is overseen by feds–but administered by each state individually.

          there are different categories of disabilty–you can apply to your state for disability benefits, and they are less restrictive than applying for fed social security benefits. if you are approved by your state, they will then approve you for state medicaid, as they assume if you are disabled under their state law, that you qualify for medicaid.

          medicare however is offered by the fed alone. in order to qualify for medicare, you must either be at least 62 or disabled according to fed social security definition of disability, which is the strictest rules.

          being on state disability and qualifying on that basis only allows you to be eligible for medicaid, the state administered coverage. being of fed social security disability you are paid about 2/3 of your most recent 40 quarters of work in which you paid into social security. in addition you are eligible not just for soc sec disability payments, but after 2 yrs of disability you then are eligible for medicare, the fed offered insurance. (it usually takes about 2 yrs to complete the request of being considered disabled). no matter where you move to, you will continue to be eligible for soc sec disability pay and for medicare (even if you move to Costa Rica) as long as you are still a US citizen. but if you are approved for disability only by your state, and thus are only eligible for medicaid, if you move out of that state, you would need to go through the disability approval process in the new state, or, you would need to apply for fed soc sec disability benefits where if you were found disabled you would then be eligible for medicare instead. if you qualify under soc sec disability as disabled, and you are also low income (less than 135% of fed poverty level) you then would also qualify for medicaid from the state you live in to provide the remaining funds not covered 100% by medicare.

          i became unable to work in april 2006. i applied for soc sec disability benefits. in sept 2008 i was approved and awarded soc sec disability benefits, and since it had taken two years since i became disabled, i was immediately eligible for medicare. medicare generally pays nearly 80% of any service, but as i am also low income, i also qualify for medicaid coverage, which covers the portion medicare does not.

          i knew a gal who according to the state office of voc rehab qualified under state law as disabled, and was also low income and qualified for medicaid (even tho most states do not qualify adults unless there are children in the household). being disabled under state law by voc rehab (the agency which does the determination) therefore qualified her for medicaid, which she otherwise could not have been eligible for. however, if she moved out the state, her disability determination would not carry over to any other state, nor would her eligibility for medicaid. she would have to requalify for disability under the new state rules by that state’s determining agency (usu this is voc rehab).

          the ins and outs of medicare and medicaid are convoluted and difficult to discern; however after 7 years, i have developed a pretty good understanding of them 🙂

      • And I just reread my comment and it seems awfully snappish to me, kat, and for that I apologize. I am genuinely pissed off, but not at all at you. I’m angry at a system that is so broken in so many ways. Please forgive me for my tone.

        • no worries, i did not take it that way at all! i was actually thinking i might have inadvertently done the same, 🙂

        • ps–when one is approved for fed soc sec disability benes, they count back to the date you first applied. if it is 2 yrs or more since you first applied when you are approved, then you become eligible for medicare. if it has been less than 2 yrs, you must wait until it has been 2 yrs since you first applied until you are eligible for medicare. so, supposing you have been awarded soc sec disability, but you need to wait 6 more months to qualify for medicare, you will already qualify for state medicaid insurance, because you have the disability award. in this case, the medicaid would cover 100% of all costs, except for small fees for drug copays (less than $5 per rx). most states medicaid coverage now has several insurance plans with private insurers, and each plan from each insurer offers the coverage required by medicaid, and may even add additional coverages. these plans are free, and it is similar to going just with straight medicaid, but each plan will have different hmo’s or ppo’s and thus a different network of providers from the others. some states still do not have separate plans from private insurers and you just go to where medicaid says they will cover.

          and lastly, it is the same for medicare. you may choose original medicare, where you deal directly with them, and go to any provider who will accept payment from them. most places do. also, as above, if you do not want straight original medicare, there are literally thousands of private insurers who offer plans called ‘medicare advantage plans’ which cover all the things medicare covers, and most also offer additional coverage, such as dentures, crown, root canals, implants, glasses/contacts, hearing aids, prostethes, etc. i myself have an advantage plan, and am able to continue wearing contacts, have dental work done (8 root canals and crowns last year, and 6 filling prior to that!), etc.

          if you qualify for both, then all your costs are covered 100%. if you got soc sec disability benes, you have medicare after the 2 yrs, if you do not qualify by income for medicaid, then you must pay the remainder of deductible, premium, copays for both original medicare, or for a medicare advantage plan. often, you will find many advantage plans offer the additional coverages original medicare doesn’t + the premiums and copays may also be less. there are also medigap plans available, which aim to fill the same void that medicaid does, by helping to cover the deductibles, premiums, and copays that are still due after original medicare has paid. you may have either a medigap policy or a medicare advantage policy, but not both. also, medicare advantage plans provide all the benefits that original medicare offers under Pt A (hospital), Pt B (outpatient, such as therapy, pcp appt, specialist, etc that is not in a hospital), and Pt. D (drug coverage). medigap policies do not provide Pts A, B, and D coverage they simply agree to pay out funds on certain (specific to ea medigap policy) for services you received and were not covered 100% that were Pts A and/or B, but not Pt. D. You may also have original medicare ( which only offers Pts A and B, not D) and then purchase a separate Pt. D plan offered by a private insurer. If you have original medicare, you are required to purchase a Pt. D drug plan.

          i wish i could do this in person, because there is so much information i wish i could share, but i would be writing for weeks, and i have already written more than enough!!

          • That actually clears up everything on my end as far as the Medicare/Medcaid issue. For some reason I never thought to mention — well, I’ve mentioned it other places, but obviously not in the comments here — I’m eligible only for SSI, not SSDI. I didn’t have enough work history when I became disabled. I worked at 16, and actually made quite a good bit of money until I was 19. Then I quit to go to school part-time and was a nanny. I was making so little doing that (I loved my girls so much I would have paid to take care of them!), plus additionally being a student, that I didn’t even have to file an income tax return. But even if I had, by 24 I couldn’t work at all. I finally applied for disability I think mid 2008 (I should have done sooner, but ironically I was too sick), but you needed — at least at that time and in the state of Colorado — forty quarters of work experience to qualify for federal benefits. I was granted disability fairly quickly by an incredibly kind judge (after an initial denial, but my understanding is they outright deny everything the first time around — the gentleman at my local Social Security office who helped me was incredibly kind as well), and my then psychiatrist’s office manager charged me a whopping $40 for not only preparing everything but attending the video hearing with me, as opposed to the 30-or-so percent of back pay I’ve been told is customary with disability lawyers. Just goes to show you, there are good people in this world.

            In any case, I’ve been able to stay on my father’s insurance because I’m a dependent, but when he turns 65 I’ll have Medicaid and only Medicaid. And it doesn’t look like I’ll be going back to work any time in the foreseeable future, as I am officially “unmedicatable” (intolerant or unhelped by every medication tried, and believe me, I have tried them all).

            So I get about $700 a month — and don’t get me wrong, I am incredibly grateful for that. But the wait list for assisted housing is about three years, and even with Medicaid and food assistance and everything else, I’ve done the math and there’s no way I could get by if I weren’t living with my parents. I’m incredibly grateful to have them, in any case, even if it’s frustrating to not be on my own at 33 — especially when everyone from my doctors to my parents to myself agrees that I would be a whole hell of a lot healthier living alone. But you get what you get, you know? 😉

            • ya SSI is a totally different thing, I even forgot to bring it up. It’s probably the one area I am not a knowledgeable on, but I did know you are not considered fed disabled (cuz that would be soc sec disability). that is why you are not eligible for medicare. but, you will always be eligible for medicaid, and since it is your only coverage, and since you are disabled. it will always pay 100%, except on the drug copays, which are minimal. if the state you live in has private insurance plans that provide the same medicaid benefits, you may find one that has a better network of providers than if you are on medicaid only (without a plan), which would help you be seen more quickly (very quickly) and give you a guaranteed pool of providers that will always accept your medicaid plan, and you can always switch your plan every year if you find one that offers additional benefits or has a network of providers that is more to your liking.

              i started working at 14, in ’86, and worked until i was 32 in 2006 when i also applied for soc sec dis benes. i got my soc sec dis award in 2008 when i was 34. i get about $950 and am now 41. so i was able to have the 40 quarters of work. because my soc sec dis amount is over $673, i don’t qualify for SSI in addition. usually, a person only qualifies for one or the other, not often for both. even on my soc sec amount, it will be very difficult for me to support myself (housing, food, utilities) when my kids move out and i no longer receive child support or their soc sec amount they receive on my behalf. so i know what you mean about you get what you get….and hope i can get something in 2 years when my kids are gone. oh—yes, housing lists are impossibly long. i was on 2 lists here for 5 years, i got on one and had to move in 3 months because my income went up when my ex started paying child support and so i was no longer within the income limit. when my name came up on the second one, they told me i was ineligible because i made $400 over the limit in a year, and that was only cuz my ex was required by the court to pay me a one time lump sum payment of $1000. if he had not made that 1 single payment that year, i would have been within the income limits.

  5. Hey Jared. Making an attempt to catch up on blog reading. Le’s see how far it gets me 😛

    I have many, many words begging to be let loose but I think I can summarize them in just one: DISGUSTING

    That’s what insurance companies are and that’s what they do. Simply disgusting

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