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A doctor's office. Photo: Getty

Singaporeans Are Staying Silent About Their Mental Health to Stay Insured

Health insurance is a multi-billion dollar industry in Singapore. But those diagnosed with mental health disorders are staying silent to avoid losing coverage.
August 20, 2020, 2:46am

Lydia Lui, 31, remembers a version of herself at age 21—a strong and capable female cadet serving in the Singapore army, able to outrun even the fastest male officers.

But a field accident in 2008 left Lui with a smashed kneecap and other bone fractions. Even harder to heal from, she says, were the deep emotional scars. Lui developed post-traumatic stress disorder (PTSD) as a result.

“The army is a physically demanding place,” she told VICE News. “I don’t blame anyone for what happened to me,” she said. “I knew what I was signing up for when I joined the army and there have been mishaps worse than mine so I’m lucky I’m still alive with minimal damage.”

After making a full recovery, Lui bought life insurance and critical illness coverage with help from the army. But it wasn’t until a year later when she returned to civilian life that she started experiencing traumatic flashbacks from her military service. She said she now gets anxious and feels suffocated in public spaces, especially among large crowds.

“It’s a struggle for me to commute by public transport,” she said. “I can’t get around on buses or trains without feeling triggered and overwhelmed by all of the sound signals and bells. It’s a sensory overload.”

The accident continued to affect Lui deeply, but with the support of her partner and family, she sought psychological help and was referred to a local government institute to begin cognitive-behavioral therapy. But during her sessions, she was “advised” by doctors not to disclose her PTSD diagnosis because it would “complicate things” and affect her insurance coverage.

“I wasn’t aware of this loophole and felt that it was unfair and discriminatory,” she said.

Insurance companies in Singapore have faced criticism for denying life insurance and other kinds of coverage to those dealing with mental health disorders, like depression and anxiety, even when it does not impact their physical conditions.

“I understand the risks of insuring someone who may be, for instance, suicidal, and therefore a threat to themselves,” Lui said. “But companies should not be denying insurance coverage to people with mental health disorders, even if it may be hereditary, because it will only discourage them from seeking help.”

Lui said she was left with two choices: either she needed to inform her insurance company about her PTSD and risk being denied coverage, or she needed to stay silent and remain insured. She chose the latter.

“I chose to remain silent about my mental health in order to protect my physical health so I decided not to declare my struggle with PTSD,” she said. “I just put it down to stress.”

According to the World Health Organization, hundreds of millions of people around the world deal with mental health disorders, like depression. In Singapore—which was ranked in 2019 as one of the world’s most overworked cities—psychiatrists like Lim Boon Leng say they are seeing a sharp rise in the number of new patients with stress-related disorders, especially during the pandemic.

“Many of us are resilient and have been coping well despite the new circumstances,” Lim told VICE News. “But we have to brace ourselves for an increase in mental health disorders. Suicide rates may also increase.”

Lim said that his patients often express concern about seeking professional help out of fear that it may negatively impact their future.

“They fear that it might affect their personal records, jobs and future applications for health insurance,” he said.

He also highlighted a lack of mental health insurance coverage options in Singapore, which further enhances the social stigma.

“Almost all companies in Singapore do not cover mental health conditions at all, even if someone does not have pre-existing conditions,” he said.

VICE News spoke with several Singaporeans who were turned away by health insurance providers without explanation.

Tabitha Rae, a private tutor in Singapore, said that she feels insurance companies are “operating without any regulation” and “cherry-picking” their customers.

“They choose who they want to insure and the lack of transparency around this is problematic and concerning,” she said.

In some cases, insurers have been said to penalize long-term customers under premium plans if they admit to having mental health disorders.

Jess Ho, a 28-year-old creative director from Singapore who was diagnosed with several mental health disorders, including bipolar disorder, shared her experience of being blacklisted by her insurance company, despite having a doctor’s letter certifying that she was physically well.

“Poor mental health is very common in Singapore given that we live in such a stressful and demanding society—we still have a long way to go in terms of acceptance,” she told VICE News.

“Insurance companies should be practicing greater understanding towards clients with mental health disorders,” she continued. “There is no acceptable reason to discriminate against a person over something like a mental illness which he or she can’t control.”

The discussion on mental health disorders and discriminatory insurance policies in Singapore has started gaining wider media coverage. In November 2019, health minister Gan Kim Yong answered questions relating to insurance coverage for patients receiving mental health counseling at public hospitals, though he did not address the issue of discrimination.

“Mental health therapy and counseling treatment are typically provided in the outpatient setting,” he wrote. “Subsidies are also available for patients receiving treatment in public healthcare institutions. No Singaporean will be denied access to necessary and appropriate healthcare because of an inability to pay,” Gan said.

Singaporean insurance companies said they are beginning to explore mental health plans, understanding the increasing demand for treatment. They denied immediately rejecting applications with mental health histories but admitted that the process is one that is still evolving.

Melita Teo, Chief Customer and Digital Officer of AIA Singapore, said the company hopes to “encourage more members of society to acknowledge mental health and psychological conditions as legitimate health concerns that require treatment and support”.

“We agree and recognize that more can be done to address mental health disorders in Singapore,” Teo said. “We do not immediately reject applications from individuals with a history of mental health conditions. Our teams review each application on a case-by-case basis and do a thorough assessment based on their respective medical history and risk profile before an outcome is derived.”

Teo added that the company launched Singapore’s “first and only” critical illness plan that provided coverage for five mental health disorders, highlighting that the sign-up rate has been a positive indicator of its success.

Meanwhile, a spokesperson from Aviva Singapore told VICE News in an emailed response that “increasing access to mental health treatments and services through insurance products is a step in the right direction to normalize these issues and allow people in Singapore to get the help they need at an affordable price.”

The company said it recently introduced a mental wellness coverage plan which provides clients and customers the flexibility to cover both inpatient and outpatient psychiatric as well as psychological treatments. Those insured under the plan will also be allowed to claim for consultations, standard diagnostic tests, treatments and medication recommended by approved psychologists and psychiatrists approved, Aviva added.

But the company’s standard insurance plans appear to have some significant exclusions when it comes to psychological or psychiatric treatment. According to an Aviva insurance document seen by VICE News, “pre-existing conditions which have existed at any time prior to the commencement or reinstatement of insurance coverage and suicide or attempted suicide, self-inflicted injury or illness—whether the person is sane or insane,” are excluded from Aviva insurance coverage. Another condition stated that benefits were not rewarded if a customer was confined to a mental institution.

“Most insurance plans have exclusion clauses for people who may have hurt themselves, avoided seeking treatment or are on medication for their illnesses and have been unable to claim successfully,” Aviva Singapore said in the email.

Insurance agent Joshua Tay was more frank. He told VICE News that he is dealing with more clients who have been diagnosed with anxiety and depression, especially during the pandemic. He tries to adopt an understanding approach but says “it isn’t always easy”, given the nature of risk management.

“When people approach insurance agents, our companies take on their risks by footing hefty hospital and medical bills to allow them to pay a small and fair premium,” Tay said. “I always try to look out for my clients and listen to their issues without any judgment. But it can be tricky when it comes to matters of the mind.”

He explained that mental health disorders may affect different people in different ways, making it difficult for companies to adopt uniform policies.

“We cannot guarantee a person’s intentions when buying insurance so as harsh as it may sound, mental health patients are deemed a risk not only to themselves but to the pool of our other existing clients,” he said.

“That is why most companies have to be very careful when insuring someone who is depressed or suicidal, not because we are ostracizing them but we have no genuine way of quantifying and verifying their intentions.”