Health Insurance: Why you should go for OPD health cover

July 7, 2020 9:59 AM

Based on the changing consumer expectations and needs, health insurance policies are getting redesigned to include OPD-related expenses.

Health Insurance, OPD health cover, OPD health insurance, out of the pocket expenses, Max Bupa’s GoActive plan, OPD expenses, Digit’s OPD Policy, Max Bupa’s Heart Beat OPD coverages either come as a part of your base plan, or secondly, they can be bought as a separate rider.

Health insurance is inevitable in today’s inflation-hit age with medical costs rising at an unabated pace. But then, have you ever wondered what if your health insurance policy might just have a considerable gap? And even a comprehensive health insurance policy may not pay you for a tooth filling or for a few appointments with your doctor.

Unfortunately, the cost of dental treatment, diagnostic tests, periodic doctor consultation, preventive check-ups and medicines, collective called as ‘out-of-the-pocket’ expenses, can disturb your savings routine significantly as they are not covered under most health insurance plans. Moreover, in India, out-of-pocket medical expenses roughly account for 62% of all healthcare costs.

What are OPD Expenses

Thankfully, based on the changing consumer expectations and needs, health insurance policies are getting redesigned to include OPD (Out Patient Department) related expenses. Many latest health insurance plans offer wide coverage for customers that include day-care procedures and treatment for vector-borne diseases to maternity benefits and cover for OPD expenses, among others. Health insurance plans that offer OPD cover assist the insured to claim expenses other than that incurred during hospitalization. The term OPD refers to expenses incurred for a visit to a clinic or a hospital or an associated facility for diagnosis and treatment based on the advice of a medical practitioner. On these visits, the patient does not have to be admitted as day-care or in-patient. An OPD cover assists the insured to claim expenses other than that incurred during hospitalisation. Moreover, compared to regular health insurance policies, there are more tax benefits associated with these plans.

Types of OPD Cover

Typically, there are two kinds of coverages available in the market to cover OPD expenses – Closed Network, and Open network OPD policies. Network specific OPD covers restricts customers to a specific network of OPD practitioners; whereas Open Network policies allow customers to go to any OPD practitioner and expenses are reimbursed. For a customer, Open network OPD policies are better as that gives flexibility to go anywhere for any OPD treatment.

Additionally, OPD coverages either come as a part of your base plan, or secondly, they can be bought as a separate rider. However, most health insurers offer coverage for inpatient, day-care hospitalisations and inpatient hospitalisation claim. In maximum cases, the policyholder gets OPD benefits such as medicines, consultations and diagnostic tests under pre-hospitalisation i.e. 30-90 days and post-hospitalisation i.e. 60-180 days. You may also get a separate defined OPD limit apart from OPD being covered under inpatient and pre and post-hospitalisations provided your policy allows the same. Though, policies with separate OPD coverage are relatively priced at a higher-end in comparison with policies giving coverage for basic inpatient hospitalisation expenses.

For instance, a health insurance plan with Rs 5 lakh sum insured for a 30-year-old individual with basic inpatient plan will cost around Rs 7,000 – Rs 10,000. Now, if someone opts for the OPD benefit up to Rs 10,000 along with the regular Rs 5 lakh sum insured health plan with the same parameters, the premium of this plan will come out around Rs 14,000 – Rs 17,000.

Who Should Buy OPD Cover

OPD cover is for everyone who think they might incur healthcare costs which do not require in-patient hospitalisation. This covers minor medications like viral fever and in cases of some chronic conditions like diabetes, arthritis, or back pain. For any other chronic condition that requires regular visits to the hospital, OPD insurance remains a must buy. When looking for health insurance costs regarding doctor’s consultation fees, health check-ups, dental treatment, pharmacy bills, diagnostic tests, and others should not go disregarded to make the most of your health insurance cover. OPD cover allows the policyholder to make claims for any expenses incurred, not including hospitalisation. However, one must learn that the OPD treatments are considered only in network clinics and hospitals. You can claim OPD expenses without an extensive wait and can make multiple claims within the same year until the limit is exhausted.

Options Available

One of the most recent plans that provide comprehensive OPD cover within your base plan is Digit’s OPD Policy (Non-Network). The policy offers OPD cover up to Rs. 10,000 and is available in two variants – PB OPD Family and PB OPD 1 Adult. The policy covers you for major OPD expenses that include Professional Fees, Diagnostics, Surgical Treatment, Medication, Psychiatric Illness and expenses on Dental Treatment and Hearing Aids. For now, the plan is available in two sum insured options – Min 5 Lakh and Max 10 lakh, you may choose any sum insured from R. 5 lakh to Rs. 10 Lakh. Some other plans offering OPD cover in the base plan include Max Bupa’s Heart Beat – a comprehensive individual/ family floater plan that offers a minimum sum insured worth Rs 15, 00,000. For OPD claims made under this policy, the maximum limit available for the policy holders is Rs 30,000.

Max Bupa’s GoActive plan offers cashless OPD coverage to the customers at affordable prices. The plan doesn’t require customers to self-finance for OPD or block their hard-earned money. It comes with OPD coverage built into the base premium. Customers buying the plan get up to 10 cashless/reimbursable OPD consultations with 10,000 doctors through Practo’s comprehensive doctor network. These could be consultations with general physicians, specialists, dentists, orthopaedics, paediatricians or with any other medical consultant as per the need of the customers. Religare Health Insurance offers OPD coverage under its Care plan wherein the OPD expenses are covered on reimbursement basis.

(By Amit Chhabra, Head-Health Insurance,

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