Health Insurance with OPD Cover

What's inside? 🧐

• Introduction
• OPD full form
• What is OPD cover?
• What are the components included in OPD coverage?
• Difference between OPD and daycare procedure
• Health insurance plans with OPD cover in 2024
• Benefits of OPD cover in health insurance
• Types of expenses covered in health insurance
• What's not covered under OPD cover in health insurance?
• What is the claim settlement process for OPD cover?
• Factors to consider while buying OPD health insurance plans
• Should you buy health insurance with OPD coverage?
• FAQs

Introduction

Inpatient and out-patient costs are constantly rising in India. Did you know that the average cost per episode of out-patient care is Rs 400 for public providers and Rs 586 for informal private providers? Say each of them visits the doctor twice a month - they will each spend Rs. 800/ Rs. 1172 every month for out-patient care, respectively. These costs can accumulate to drain your savings and someone with a chronic condition or a senior citizen who needs regular doctor visits may struggle to cope with such hefty expenses.

But, worry not! Some insurers cover out-patient or OPD expenses as well.

In this article, we discuss out-patient expenses in detail and how they are covered under your health insurance policy.

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OPD Full Form

"OPD" stands for Outpatient Department in the medical world. It is the part of a hospital or healthcare facility where you can receive medical check-ups, tests, and treatments without getting admitted overnight. If you have a health insurance policy that covers OPD expenses, your insurer will take care of the costs for these outpatient services. So, you can see a doctor, get tests done, or receive treatment without worrying about paying anything from your pocket.

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What Is OPD Cover?

The Out-Patient Department, or OPD, is the area of a hospital devoted to treating outpatients - those who don't require hospitalisation for diagnosis or treatment.

For example, dressing a wound or applying a plaster cast can be done in the hospital's OPD without being admitted to the hospital - and hence, would be considered as an OPD treatment.

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What Are The Components Included In OPD Coverage?

The cost of medical care can be enormous, and most health insurance policies do not cover out-patient treatment expenses, as mentioned earlier. However, if your policy includes an OPD cover or offers it as an add-on, you will be financially protected against the following expenses -

• Diagnostic tests
• Consultations
• Out-patient dental treatment
• Medical drugs

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Difference Between OPD And Daycare Procedure

The Outpatient Department (OPD) and daycare procedures both offer medical care without the need for overnight hospitalisation, but they differ in various aspects –

Aspect | OPD (Outpatient Department) | Daycare Procedures Meaning | In OPD, you receive treatment or diagnosis or consult with a doctor without being admitted to the hospital. | Daycare procedures require less than 24 hours of hospitalisation such as  chemotherapy, cataract surgery, etc Hospitalisation | OPD does not involve hospitalisation as you only visit the hospital, get necessary medical services, and leave. | Daycare treatments require compulsory hospitalisation. Insurance Coverage | OPD expenses can also come as an inbuilt coverage but are usually not covered by most health insurance plans. However, some plans may offer coverage as an optional benefit at an extra cost. | Daycare treatments are covered by almost all health insurance plans, with variations in the specific treatments covered.

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Health Insurance Plans With OPD Cover In 2024

Listed below are the specifics of each plan offered by different insurers -

Insurance Company | Plan Name | OPD Coverage Acko | Platinum Health Insurance | Consultations: 1/ 2/3/4/5/6/7/8/9/10/ Unlimited Per Consultation limit: Rs 250 / 500 / 750 / 1000 / 1500 Prescribed Diagnostic Tests: 1/ 2/3/4/5/ Unlimited Per diagnostic test limit: Rs 500 / 750 / 1000 / 1500 / 2500 Prescribed Pharmacy: 1/3/4/6/7/9/10/12/13/15/ Unlimited Per pharmacy limit: Rs 500 / 750 / 1000 / 1500 / 2000 / 2500 / 3000 No. of OPD Treatment covered: 1/ 2/3/4/5/6/7/8/9/10/ Unlimited Limit: 5k/10k/15k/20k/25k/30k/40k/50k/75k/100k Aditya Birla | Activ Care (Premier) | Covers up to Rs. 2,500 in addition to the sum insured, per tests or consultation. Bajaj Allianz | My Health Care Plan | Tele (Insta) Consultation Cover: Maximum 5 consultations per day, 15 online consultations per month and only 1 active doctor consultation. Doctor Consultation Cover (In-clinic): Sub-limit of Rs. 500 for general physician and Rs. 1,200 for specialists per consultation as specified under the plan. You can use up to 50% of the OPD sum insured. Doctor Prescribed Lab and Radiology Cover: Up to 50% of the OPD sum insured. Annual Preventive Health check-up cover - 1 voucher each policy year Care Insurance | Care | The maximum coverage options you choose are: 5K/10K/15K/20K/25K/30K/35K/40K/45K/50K ICICI Lombard | Health AdvantEdge | Outpatient Consultations: 0/6/8/12/18 times Routine Diagnostic & Minor Procedure cover: Rs. 1k/1k/2k/3k/5k Pharmacy cover: Rs. 1k/1k/2k/3k/5k Physiotherapy Sessions: 0/6/8/10/12 Tele-Consultation: 12/12/12/18 Unlimited times Manipal Cigna | ProHealth Prime (Advantage) | Covers up to Rs. 20k/30k/50k per policy year. However, there is a sub-limit of 20% of the sum insured on pharmacy. National Insurance | Parivar Mediclaim Plus | Covers up to chosen limit 

(options: Rs. 2k/3k/4k/5k/10k/15k/20k/25k).

The limit will be over and above the sum insured. New India Assurance | Premier Mediclaim (Plan B) | Covers up to Rs. 10,000/- cumulatively Niva Bupa | Health Premia (Platinum) | Covers up to Rs. 50,000/- per policy year Reliance | Health Infinity | Covers up to 100% of the sum insured (additional amount). Prescription drugs are covered to 35% of the sum insured. SBI | Health Edge | Covers up to Rs. 5,000 per covered member Star Health | Comprehensive | Covers up to maximum either Rs. 5k/10k/15k depending on the sum insured you choose per policy year, with a limit of Rs. 300 per consultation. Tata AIG | Medicare Premier | Covers up to maximum 5K/ 7.5K/ 10K/15K/20K -  The limit will be over and above the sum insured.

Please note that the data in the table is as of January 2024.

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Benefits Of OPD Cover In Health Insurance

Here are some of the advantages of having an OPD coverage in your health insurance policy -

• You can get financial protection from expenses incurred for routine check-ups, pharmacy bills, and diagnostic test charges.
• If you suffer from chronic conditions like arthritis, diabetes or asthma that require constant medical care and consultations, OPD cover might help you save on your funds.
• The OPD cover of some insurers, such as Royal Sundaram, New India Assurance, etc., includes dental treatments.

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Types Of OPD Expenses Covered In Health Insurance

OPD cover provides coverage for the following -

1️⃣Out-patient Consultation

The OPD cover protects you against expenses such as doctor consultations, diagnostic tests, pharmacy bills, etc. Some insurers, like Royal Sundaram, National insurance, ICICI Lombard, etc., provide coverage for such expenses.

2️⃣OPD Ophthalmic Eye Treatment

Some insurers like Star Health cover expenses associated with eye treatments. However, coverage is only available if the eye treatment is done by a licensed ophthalmologist in an OPD department of a hospital. The treatment must also be deemed medically necessary to treat the eye condition. You should keep in mind that they even cover the cost of spectacles and contact lenses.

3️⃣OPD Dental Treatment

Digit Insurance, HDFC Ergo, etc., provide coverage for dental treatment under their OPD cover. Certain dental treatment may not be covered by some insurers and the coverage may be subject to certain conditions.

• In Digit Insurance, dental treatments are covered only if the expenses are incurred as a result of an accident.
• HDFC Ergo covers only the expenses related to extractions, X-rays, amalgam, root canal treatments, and prescribed medications.
• Insurers like HDFC Ergo apply a 3-year waiting period for OPD cover of dental expenses. As a result, you'll have to wait three years to be able to claim the OPD benefits.

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What's Not Covered Under OPD Cover In Health Insurance?

Exclusions are conditions/treatments that are not covered by the OPD cover. Some of the exclusions are as follows -

1️⃣OPD Treatments Outside India Not Covered

The OPD cover will not pay for any out-patient treatment taken outside of India unless it is explicitly stated in the policy wording.

For instance, Care Health Insurance offers OPD worldwide coverage in addition to regular OPD coverage. As a result, you can get OPD coverage for treatments worldwide as well as in India.

2️⃣Cosmetic Dental Treatments Not Covered

Insurers, like National Insurance, specify in their policy documents that cosmetic dental treatments - such as brightening, straightening, reshaping, and repairing teeth are not covered.

In addition, treatments such as crowns, veneers, bridges, tooth-coloured fillings, implants, and whitening are also excluded from the scope of coverage.

However, ICICI Lombard covers such expenses only in the event of an accident. Hence, regular cosmetic treatment that isn't accident-related shall not be covered.

3️⃣No Coverage For Spectacles, Hearing Aids, etc.

Some insurers, like Digit Insurance, have stated in their policy documents that they will not cover the cost of contact lenses, spectacles, hearing aids, or ambulatory devices, etc.

4️⃣Counselling Sessions Not Covered

Any psychological therapy session conducted under the supervision of a psychologist is usually not covered.

Note: These are some of the most commonly mentioned exclusions. Apart from these, there may be other conditions as well, depending on the insurer.

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What Is The Claim Settlement Process For OPD Cover?

The OPD claim process is similar to other health insurance claims. First, confirm that your health insurance policy includes OPD coverage, as it is not always a standard feature that comes with all policies. Hence, you should check your policy details to ensure OPD expenses are covered.

There are two ways to initiate a claim request for OPD expenses –

1️⃣Cashless Claims

If you choose to receive treatment in a hospital listed in the insurer's network, they will directly settle the bills with the hospital. The network hospital is one that has a tie-up with your insurance company. If your chosen hospital is on their approved list of cashless hospitals, the insurance company handles the payment directly. You will only have to pay for expenses not covered by your insurer.

2️⃣Reimbursement Claims

In this case, you pay the hospital bill and treatment costs yourself, then submit a reimbursement claim to your insurer. They will reimburse you according to the policy terms and conditions.

You should keep in mind that not all health insurance plans handle OPD services the same way. Some plans offer cashless OPD services only if you go to specific network hospitals, such as  Aditya Birla Health - Activ Care (Premier), Acko - Platinum Health Insurance, Manipal Cigna - ProHealth Prime (Advantage), etc.

Also, there are certain plans that provide OPD coverage only on a reimbursement basis, such as Reliance - Health Infinity (Plan A), SBI General Health Edge, Care Insurance Care, etc.

There are also plans, like Bajaj Allianz - My Health Care Plan, that allow you to choose between cashless and reimbursement processes for OPD coverage. Hence, depending on the plan's claim settlement facility, you can select the method that suits you best when applying for a claim.

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Factors To Consider While Buying OPD Health Insurance Plans

Here are a few factors to keep in mind when you purchase health insurance with OPD coverage –

1️⃣Coverage Limits And Restrictions

Many plans set limits on outpatient department services, either as a percentage or a maximum amount. Some plans also have restrictions on the number of consultations, diagnostic tests, sub-limits on pharmacy or prescribed drugs, etc. For example, Acko Platinum Health Insurance plan specifies limits on the number of consultations and the maximum cost per consultation. You can find a snapshot of their coverage limits in their prospectus –

For consultations: 1/2/3/4/5/6/7/8/9/10/ Unlimited

Per consultation limit: Rs 250 / 500 / 750 / 1000 / 1500 For prescribed pharmacy: 1/3/4/6/7/9/10/12/13/15/ Unlimited

Per pharmacy limit: Rs 500 / 750 / 1000 / 1500 / 2000 / 2500 / 3000 For prescribed diagnostic tests: 1/ 2/3/4/5/ Unlimited

Per diagnostic test limit: Per pharmacy limit: Rs 500 / 750 / 1000 / 1500 / 2500 OPD Treatment: 

No. of treatments covered: 1/2/3/4/5/6/7/8/9/10/ Unlimited

Limit: 5k/10k/15k/20k/25k/30k/40k/50k/75k/100K

2️⃣Scope Of OPD Coverage

OPD expenses generally include three main categories – doctor consultations, diagnostic tests, and pharmacy costs (medicines). It is important to note that not all health insurance plans cover all three aspects. For example, Bajaj Allianz My Health Care Plan excludes pharmacy expenses.

There are also other exclusions to be aware of, such as OPD expenses for dental or cosmetic treatments, OPD expenses incurred overseas, etc. This is why it is essential to carefully review the list of inclusions (covered services) and exclusions (services not covered) in your policy.

Make sure that the policy covers the specific outpatient services you are likely to use, including consultations, diagnostic tests, pharmacy expenses, etc. This ensures you have the coverage you need for your anticipated healthcare needs.

3️⃣Copayment Clause

Some plans, like Reliance Health Infinity, may also include a copayment clause. Copayment is a certain percentage of the approved claim amount  you need to pay from your end before the insurer covers the rest. If you prefer to avoid spending your hard-earned money, consider choosing a plan that offers OPD coverage without any cost-sharing conditions.

4️⃣Waiting Period

You should make a note of waiting periods associated with OPD coverage. For example, the TATA AIG Medicare Premier Plan offers OPD coverage only if your policy has been active for at least two continuous policy years.

5️⃣Transfer Of Benefits

You should check if your chosen OPD cover allows you to carry over unused benefits to the next policy year. While Niva Bupa Health Premia (Platinum) Plan permits this, Bajaj Allianz - My Health Care Plan does not provide the option to carry over this benefit to the next year.

6️⃣Beware Of Other Conditions

You should also be aware of other hidden conditions that come with this cover. For instance, the New India Mediclaim Plan offers OPD benefits only after two continuous claim-free years. This is why it is wise to review the policy document thoroughly to understand the terms and conditions, to avoid any nasty surprises in the future.

Note: This is only an indicative list of the general terms and conditions. Please check with your insurer before investing in the policy.

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Should You Buy Health Insurance With OPD Coverage?

You can consider buying a plan with OPD coverage if you have specific healthcare needs requiring frequent outpatient services. While this cover can be advantageous for anyone's well-being, individuals with such requirements can particularly benefit from including  an OPD cover in their health insurance policies.

OPD coverage is worth considering if you fall under any of these categories –

1️⃣You or your family regularly visit doctors, specialists, or healthcare providers. An OPD cover can ease the financial burden of these outpatient visits.

2️⃣You prioritise preventive healthcare, and you undergo routine health check-ups. In this case, an OPD cover with preventive check-up coverage is a suitable choice.

3️⃣You have chronic medical conditions that need ongoing monitoring or outpatient treatments. In this case, an OPD cover can assist in managing associated expenses.

4️⃣You are anticipating frequent diagnostic tests, laboratory work, or imaging studies. In such cases, an OPD cover can provide financial support for these outpatient services.

5️⃣You are a senior citizen and don’t often require inpatient hospitalisation but need regular medical check-ups. In such a case, you will be able to benefit from OPD coverage.

6️⃣You require coverage for prescribed medications. Some OPD covers also include outpatient pharmacy expense coverage, helping you alleviate the financial burden associated with such costs.

OPD coverage in health insurance goes beyond hospital stays and includes outpatient services in a health insurance plan. Unlike traditional plans that mainly cover hospitalisation expenses, OPD coverage encompasses routine doctor visits, diagnostic tests, medications, etc., that doesn't require hospitalisation. This is important for managing your day-to-day health costs, encouraging preventive care, and catching issues early. Thus, it is crucial to thoroughly research various health insurance plans offering this coverage before selecting the optimal plan. Or, you can leave this task to the financial experts at MyInsureBuddy, allowing them to guide you in making the right decision.