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Covering OPD Cover in Health Insurance

Published On Aug 22, 2019 12:00 AM By Chinansuka Agarwal

In health insurance, you must have come across the term OPD (outpatient department). These are the cases where one gets treated for illness without hospitalisation. In most cases, these expenses are paid out of pocket. Getting affordable and comprehensive OPD cover under health insurance is a difficult task. Nevertheless, some of the insurance companies such as Religare, Max Bupa, Apollo Munich, ManipalCigna, etc. do provide cover for OPD treatment.

There are mainly two types of OPD coverage available. Either it is provided as part of the base plan, or it is offered as a separate rider. Generally, the coverage under a health insurance policy is for inpatient and daycare hospitalisation. In case the patient is hospitalised, then the OPD cover is provided under the base policy under pre and post hospitalisation benefit. These include the coverage for medicines, consultations and diagnostic tests.

“However, policies with separate OPD coverage are at relatively higher premium compared with policies giving basic inpatient hospitalisation coverage,” said Nikhil Apte, chief product officer, Royal Sundaram General Insurance Co. Ltd. How does it work? “For example, a product of Rs. 5 Lakh sum insured for a 30-year-old individual, OPD benefit will be Rs. 5,000. The premium of this plan comes out to be Rs. 14,224 inclusive of GST annually. Now if someone opts for basic inpatient plan then the premium will be around Rs. 5,795 inclusive of taxes with the same parameters,” said Apte. Thus, it goes for a significant difference of Rs.7000 to Rs. 8000 in the premium for the basic plan and the plan with OPD benefit.

OPD cover either comes as a blanket OPD cover where a certain amount is given, which can be used wherever or as a cashless OPD, which can only be used in specific network hospitals. Cashless OPD is a cheaper option when compared to blanket OPD cover. Yet, due to the unorganised nature of the OPD value chain, in most cases, the insured is not able to avail its full benefits.

“OPD cover helps the insured claim expenses other than inpatient ones. As independent doctors or clinics are not regularised in their fee structure and do not fall in the same line as inpatient hospitalisation, this is a challenge,” said Anand Roy, joint MD, Star Health and Allied Insurance. 

No doubt, there are certain challenges with the OPD coverage. Though, if you do wish to buy one, it is undoubtedly recommended to consult your health insurance advisor.

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