While health insurance compensates you for your hospitalization expenses in the case of extreme health conditions, it may not pay you for regular check-ups or appointments with your doctor. In such a situation, should you go for a health insurance policy that can cover outpatient department (OPD)-related expenses?
Generally, OPD treatments require frequent visits to hospitals as it includes treatment for ailments, regular health check-ups, or follow-up for ongoing medication.
While taking OPD treatment, patients are not required to be hospitalized but can visit any associated facility in the hospital. All this results in hefty reimbursement bills for an insurance company; hence mostly OPD coverage is not part of a health insurance policy.
Moreover, daycare procedures, inpatient treatment and naturopathy treatments are not covered under OPD expenses. Besides, cosmetic treatments and self-inflicted injuries are also not covered.
Purchase options: OPD coverage is part of a base regular health policy, and it can be bought as a separate rider, too.
Most health insurers offer coverage for inpatient, daycare hospitalizations and inpatient hospitalization claims when you look closely. In maximum cases, the policyholder gets OPD benefits such as medicines, consultations and diagnostic tests under pre-hospitalization, that is, 30-90 days and post-hospitalization, that is, 60-180 days. The policyholder can also get a separate defined OPD limit apart from the OPD being covered under inpatient and pre- and post-hospitalizations cover, provided that the regular health policy has in-built OPD coverage available.
Rakesh Goyal, director, Probus Insurance, said, “There are health insurance policies that offer the OPD cover as an add-on cover. However, for this, they do charge some extra premium. This add-on cover would include secondary treatment costs, that is, if the insured is not admitted into the hospital as a daycare patient and comes as a valuable purchase for people who tend to visit the hospital frequently.”
Benefits: Health insurance policies that include OPD coverage benefit policyholders in the following ways: It is beneficial for patients who require frequent hospital visits for OPD consultations. The insured may be reimbursed for large pharmacy bills. OPD coverage is extremely beneficial for patients with pre-existing medical conditions that necessitate frequent medical consultations. Immuno-compromised people may also benefit from OPD health insurance. People with chronic medical conditions such as asthma, diabetes, arthritis, thyroid disease and others who require regular doctor consultations can benefit from OPD coverage.
Amit Chhabra, head – health and travel insurance, Policybazaar.com, said OPD coverage is available via a variety of individual health policies. “The sum assured in the majority of these plans ranges between ?5,000 and ?20,000, but there are some that go much higher. Some policies include sub-limits in the OPD sum assured for specific treatments such as physiotherapy,” Chhabra added.
Reasons to buy OPD cover: Anyone can buy OPD health insurance cover. But it can be only beneficial for patients who are undergoing treatment that requires regular or frequent OPD visits. However, you must also understand that the terms and conditions of OPD treatment vary from policy to policy and from insurer to insurer. For instance, some policies may provide cover for vaccinations, while others may restrict you from using specific chemists.
Goel said, “It is not suggested to include OPD cover in a health insurance policy, as OPD requires a limited cost involvement which a policyholder can easily afford. However, in case a person has any pre-existing disease, which demands a regular doctor consultation, suffering from chronic diseases, having low immunity, and higher prone to vector-borne diseases, then a policyholder can opt for an OPD cover to get financial support from his regular health insurance.”
However, the premiums of policies covering OPD treatment are a bit higher compared with those that do not cover. For instance, you may have to pay an additional Rs. 5,000 to 8,000 to get an OPD cover of Rs. 10,000-15,000 sum insured. Besides, the OPD cover comes with a deductible. Hence, given that the covers are usually priced at 70-80% of the maximum claim, and the claim process can be cumbersome, getting an OPD cover may not be very valuable.
“Since OPD charges fall on a high side of cost and are frequent, OPD coverage makes a health insurance plan relatively expensive. While a normal health insurance policy premium comes around Rs. 12,000 at best, the same policy would come for Rs. 48,000 for Rs. 50,000 OPD coverage,” said Goel. He added that although the OPD cover comes with a set of valuable benefits, one must understand that the price of such coverage might be on the higher end compared with the regular health policy premium. Hence, one must analyze self and the family usage of primary healthcare to figure out whether this plan is beneficial or not.
