OPD

What Is OPD?

OPD or Outpatient Department is where basic cases requiring optimum medical attention are treated. To avail OPD treatment, one simply has to visit the doctor’s clinic and pay the consultation charges. In case of a hospital, it is the general OPD ward where patients are given medical assistance and treatment.Under OPD treatment, one is not required to stay in the hospital or get admitted. 

OPD In Health Insurance

OPD in health insurance is covered by many health insurance companies. Under OPD cover, policyholders are allowed to file their claim for expenses incurred without hospitalization. Health insurance policies covering OPD provide cover for diagnostic or minor procedures as well as the cost of medicines. One of the best features of OPD cover in health insurance is that it provides cover for expenses that are generally not covered by regular health insurance plans. In comparison to other health insurance policies, the sum insured under OPD cover is calculated on the basis of the age of the insured individual. Needless to say, health insurance with OPD cover provides extra financial protection. 

Why Is OPD Cover Necessary?

Buying health insurance with OPD cover is a necessity in today’s time due to the following reasons:

  • Rising Need: The evolving sedentary lifestyle brings along many chronic illnesses, which in turn add to the overall expenditure on medical treatment. It is important to have health insurance with OPD benefit so that daily medical expenses can be covered without any financial concerns. 
  • Lack of Healthcare Records: Our country does not have organised health records at the national level, which is the cause of hesitation among insurers for underwriting the risks. Having a plan with OPD treatment can help one avail the best outpatient treatment without having to bear the consequences of operational flaws. 

Eligibility Criteria to Avail OPD Benefit

OPD benefit does not come with any specific eligibility criteria. Any individual who is feeling unwell can go to a doctor’s clinic and avail medical treatment. 

Please note that the eligibility for OPD cover depends on the health insurance policy you have purchased. If OPD expenses are covered under your health insurance policy, you can avail all benefits for the same.

Features of OPD Health Insurance Cover 

Below mentioned are the major features of OPD health insurance cover:

  • Initial point of contact in medical treatment
  • Highlights health promotion and disease prevention
  • Facilitates screening and investigations for hospital admission
  • Easy access to doctors or medical practitioners
  • Perfect for general illness prevention or vaccinations

Benefits of OPD Cover In Health Insurance 

Some of the key benefits of buying health insurance with OPD benefit include:

  • Additional Coverage: When you buy health insurance with outpatient expense coverage, you get an additional protection that is not provided by regular plans. 
  • Cashless Facility: Some health insurance companies provide cover for OPD benefit under a cashless scheme with additional premium.
  • Sum Insured: Health insurance plans with OPD benefit have their sum insured determined based on the age of the insured. If it is a floater policy, the age of the eldest member is considered.
  • More Tax Benefits: Policies covering OPD expenses provide more tax benefits in form of tax exemption on the premium paid. Furthermore, there is no tax deductible at source for claims.
  • Multiple Claims: OPD cover in health insurance provides policyholders with the freedom to claim reimbursements many times, as and when the expenses are done. 
  • Reimbursement of Pharmacy Bills: Health insurance policy covering OPD benefit reimburses pharmacy bills, thereby being one of the biggest benefits for people with regular pharmacy bills.
  • Covers Multiple Expenses: Policies with OPD benefit provide cover for multiple medical bills, even those for hearing aid, crutches, spectacles, contact lenses, dentures, and many others that regular health insurance plans do not cover.
  • Carry Forward Feature: Some health insurance companies allow a fixed, specific percentage of the sum insured to be carried forward if the cover remains unutilized in the policy period. 

What Is Covered Under OPD? 

The inclusions under OPD include:

  • Doctor’s fees
  • Diagnosis tests, x-rays
  • Crutches, wheelchair
  • Routine check-up, vaccination
  • Hearing aid
  • Minor surgeries, dressing
  • Dental treatment 
  • Spectacles, contact lenses (some plans)

What Is Not Covered Under OPD?

The exclusions under OPD include: 

  • Physiotherapy
  • Cosmetic treatment expenses
  • BP monitors, thermometers
  • Vitamins and supplements
  • Dietician fees, consultation

Difference Between OPD and Day Care Treatment 

Many health insurance policy buyers get confused between OPD treatment and day care treatment. OPD and day care treatment are quite different from each other contrary to what most people mistakenly perceive them to be. Here are some of the prime aspects mentioned that make the two different from each other: 

  • Hospital Admission - While OPD treatment does not require hospital admission or hospitalization, day care treatment requires the patient to be hospitalized for less than 24 hours. 
  • Scope of Coverage - Most health insurance policies provide day care procedure coverage, whereas OPD treatment expenses are generally not included in health insurance policies, unless mentioned in a specific manner.
  • Level of Coverage - Day care procedures are covered up to the sum insured and do not have any limit on the coverage of treatment, OPD treatment does not cover up to the sum insured and comes with a sub-limit.

Health Insurance Companies Offering OPD Cover 

Here is a list of some of the companies that provide health insurance with OPD coverage. 

Please note that the ranking of the companies has been done based on the Claim Settlement Ratio of CSR for the year ended March, 2019. 

Health Insurance Company 

Health Insurance Policy With OPD Cover 

Claim Settlement Ratio 

Bajaj Allianz 

Tax Gain

93.68%

Care Health Insurance 

Care 

92.83%

Max Bupa 

GoActive & Heartbeat

84.15%

HDFC Ergo 

Health Maxima

83.66%

Digit 

Digit Health Plus 

83.08%

ICICI Lombard

Complete Health Insurance

78.32%

(*Claim Settlement Ratio As Per IBAI’s General Insurance Claim Insights Handbook For Policyholders - 4th Edition)

Who Should Buy OPD Health Insurance Policy?

You should look forward to buying health insurance with OPD coverage if: 

  • You incur pharmacy and other healthcare expenses on a regular basis.
  • Suffer from chronic illnesses like diabetes, sinusitis, arthritis, and others and require regular doctor visits. 
  • Have low immunity and are more prone to catching illnesses. 

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Health Insurance Opd FAQs

  • What are the options of buying health insurance with OPD?

    You can either choose a health insurance policy providing OPD cover as an in-built feature or buy a health insurance plan that provides OPD benefit as an add-on cover by paying additional premium. 

     

  • Will I get tax reduction with health insurance having OPD cover?

    Yes! You will get tax reduction benefits on buying health insurance with OPD cover.

     

  • Is there any waiting period associated with OPD cover in a health insurance policy?

    Yes! But, the waiting period for availing OPD benefit is quite less, i.e., 90 days. You can claim OPD expenses within 90 days of taking a health insurance policy. Remember, some policies do not have a waiting period for OPD claims. 

  • How can I file a claim for OPD expenses?

    OPD covers are like indemnity-based health insurance policies. You can claim OPD expenses after submitting the desired documents. The process of OPD claims is quick and easy.

  • Does OPD cover expenses incurred on day care treatment?

    No! OPD and day care treatment are different from each other, thus OPD benefit does not provide cover for day care treatments.

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