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Health Insurance With OPD Cover

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OPD Health Insurance

Outpatient treatment refers to medical services that are provided to patients who do not require an overnight stay in a hospital. In outpatient treatment, a patient undergoes diagnosis, treatment, or consultation and returns to their homes on the same day. The services usually include therapies, consultations with doctors and specialists, various diagnostic tests, etc.

Advancements in healthcare have resulted in quite a few treatments being available as OPD treatment, i.e. outpatient department treatment. Though the cost of OPD treatment and consultations might not be a lot as compared to inpatient treatment expenses, these can add up. Over an entire year, these costs can pile up and set you back. You can opt for health insurance to protect your finances against such expenses. OPD coverage in health insurance is just the thing you need.

What is OPD treatment?

OPD or outpatient department is when a patient visits the hospital and returns home the same day, after undergoing some form of medical assessment or treatment. In other words, if the treatment or assessment does not need hospitalisation, it is usually known as OPD treatment. Most hospitals have various departments in OPD, where the patient can consult a specialist. Common examples of departments include oncology, orthopaedics, paediatrics, general medicine, etc.

What is OPD cover?

OPD cover is a type of health insurance plan, that covers expenses related to doctor consultations, diagnosis tests, and even medical prescriptions. A standard health insurance plan might not offer coverage for OPD expenses. Opting for an additional OPD cover will safeguard your finances against such regular expenses.

Why opt for a HI plan with OPD benefits?

There are quite a few studies that prove that OPD expenses can be quite high in the country. The average cost of OPD visits can range between Rs. 94 for a visit to a government hospital to Rs. 2,213 for a visit to a private hospital. Some estimates show that OPD expenses amount to almost 62% of overall healthcare expenses in India.

A sedentary lifestyle and work practices have resulted in an uptick in the number of diabetes and hypertension cases. These require regular diagnostic tests and treatment. While it might seem a bit less upfront, these costs can add up. People who maintain a healthy lifestyle and workout regularly, are also prone to injuries in the gym. Choosing a health insurance plan with OPD benefits will help you save money, for regular hospital visits.

Who should buy health insurance with OPD coverage?

A health insurance plan with OPD coverage can be a sensible choice for a lot of reasons. Here are some common groups of people, who should consider getting an OPD cover.

Senior citizens
Senior citizens

As a general rule of thumb, senior citizens should have health insurance coverage. However, an OPD cover can be even more effective for seniors, since the probability of a hospital visit is much higher. They might need to visit a hospital for OPD treatment on a regular basis or for minor injuries or even dental care.

Gym goers
Gym goers

One might wonder, whether a OPD cover is for people who visit the gym or workout regularly. Yet, this group needs an OPD cover, since people who workout regularly, are prone to injuries. Back and knee injuries are the most common. And these would require you to avail of OPD services in a hospital.

Working professionals
Working professionals

A large number of working professionals are covered by health insurance plans. However, these plans are usually restrictive and the sum insured can be a bit underwhelming at times. To complement a corporate or employer health insurance plan, an OPD cover can be ideal. It will not only help you save money in the form of taxes but also give an additional layer of protection.

Young people
Young people

A lot of people in the age group of 25 to 40 years opt for health insurance plans. Since age is on their side, they can secure a health plan at much more affordable rates and easily complete waiting periods for health ailments. You can complement the plan with an OPD cover, which you are more likely to use. Irrespective of how healthy a person is, there is a possibility of visiting a hospital a few times a year.

Benefits of OPD expenses

A lot of people are usually content with just a health insurance plan. However, opting for an OPD cover can be beneficial. Here are some of the benefits of choosing such a cover.

1. You can enjoy tax benefits when you opt for OPD coverage under Section 80D.
2. People who suffer from long-term diseases and who need frequent visits to the hospital will benefit from this coverage. Diabetes and hypertension are two such examples.
3. The cost of regular visits to a doctor or hospital might not seem much for one instance. However, on adding it for an entire year, the amount can be a bit significant.
4. Should you opt for the OPD cover, the policy will take care of various expenses such as diagnostic tests, doctor consultations, prescriptions, etc. Thus, allowing you to focus on your health rather than being constantly bothered by money.

Coverage in health insurance

A health insurance plan with OPD coverage acts like any other insurance plan. Your insurance provider will offer coverage for various health contingencies in exchange for the premium that you pay. However, the coverage is not limitless. Here are the inclusions and exclusions of a standard OPD cover plan.

Inclusions

  1. Any fees related to professional consultation and examinations for assessment of a health condition.
  2. The cost of buying medicines and drugs that are prescribed by the doctor.
  3. The cost of dental treatments if it is recommended by your doctor.
  4. The cost of hearing aids for people who are developing serious hearing impairment.
  5. Fees related to diagnostic tests such as x-rays, CT scans, MRIs, pathology tests, etc. to diagnose a health ailment.
  6. The cost of minor surgeries that do not require admission to the hospital such as dressing of accidents, sutures, animal bite cases, etc. that are performed by a doctor.

Exclusions

  1. Vitamin supplements
  2. Thermometers
  3. Contact lenses
  4. Spectacles
  5. Physiotherapy
  6. Blood pressure monitors
  7. Glucometers
  8. Walkers
  9. Cosmetic surgeries
  10. Consultation for dieticians

Which OPD health insurance plan should you buy?

Here are some of the health insurance plans that offer OPD benefits for you to avail.

1. Bajaj Allianz Tax Gain
The Bajaj Allianz Tax Gain is a great family floater plan. Tax gain offers to cover hospitalisation expenses as well as OPD expenses. And both under one plan. You can file a claim for OPD cover for various conditions such as dentures, dental procedures, crutches, etc.

2. Cholamandalam Family Healthline
Family Healthline plan offers the benefits on both individual and floater basis. To get access to OPD cover, you will need to opt for the add-on by paying a small premium. You can use the cover for hearing aids, spectacles, contact lenses, etc.

3. Niva Bupa Go Activ Health Plan
For regular hospital visits, the Go Activ Health Plan is perfect. And unlike a few other plans in the list, the benefits are not available as an add-on. The plan offers up to 10 OPD consultations, that can be reimbursed or can be cashless and are available through Practo.

4. Star Out Patient Care Insurance
The plan is curated for OPD treatments. The sum insured by the plan ranges from Rs. 25,000 to Rs. 1 lakh. Outpatient Care Insurance even offers coverage for AYUSH treatments, apart from the ophthalmic cover, dental cover, pharmacy, diagnostics, and physiotherapy. You can choose either on an individual or floater basis.

5. Digit Health Insurance with OPD cover
The plan from Digit offers the benefits of standard hospitalisation and OPD benefits together. OPD benefits cover diagnostic fees, medicine bills, dental treatments, hearing aids, minor surgeries, consultation fees, etc. You can also avail of hospitalisation benefits with no room rent cap, health checkups, daycare procedures, surgeries, and no copayment, among others.

6. ManilaCigna Health Insurance
It is a comprehensive health insurance plan that caters to most medical needs. You can opt for the ProHelath Prime Advantage plan, which allows you to select a sum insured in the range of Rs, 20,00 to Rs. 50,000 per year for OPD benefits. Alternatively, you can choose the Health 360 OPD add-on with any other plan, where the sum insured ranges between Rs. 20,000 and Rs. 30,000 with increments of Rs. 5,000 and a sum insured between Rs. 30,000 and Rs. 50,000 with increments of Rs. 10,000.

7. Aditya Birla Activ Health Enhanced Platinum Plan
The plan is available as a family floater or individual basis and the sum insured ranges between Rs. 2 lakhs and Rs. 2 crores. The policy covers expenses of up to 10% of the OPD limit per visit to a physician and 50% of the limit for diagnostic and medicine, each.

8. Bharti AXA Health AdvantEdge
The OPD cover in the plan is available for both dental as well as medical expenses. The OPD cover is limited to 0.5% of the total sum insured of the health insurance plan or Rs. 1 lakh, whichever is less. The cover includes consultations, physiotherapy, pharmacy, etc.

OPD eligibility criteria

Should you decide to opt for OPD coverage in health insurance, you would need to meet the following eligibility criteria.

1. You can choose an OPD cover for your children. Provided they are at least 90 days old and less than 18 years old as well.
2. Standard coverage applies to adults between the ages of 18 years and 65 years. The actual age limits might differ a bit, depending on the insurance provider.
3. For senior citizens, above 65 or 70 years, you can look for exclusive plans from insurance providers.

How to buy health insurance with OPD coverage?

Once you decide to buy a health insurance plan with OPD coverage, choosing the right insurance provider is the next sensible step. Here are a few simple steps to help you buy the right health insurance plan with OPD coverage.

1. Access the website or application of any preferred insurance provider.
2. Alternatively, you can even visit the website or application of an insurance aggregator.
3. Search for health insurance option on the platform.
4. If you are on the platform of an insurance provider, you can choose a health insurance plan.
5. If you are on an insurance aggregator platform, you can compare different plans and choose a plan that offers the most value and coverage. You can view details of the plans and coverage on offer.
6. Proceed to purchase the plan.
7. Enter all the details such as contact information, medical history, address, etc.
8. Upload all the documents required by the insurance provider.
9. Make the payment for the plan.

Once you complete the above steps, you will receive a digital copy of the insurance in your email account.

Processes to raise a claim for OPD expenses

If you want to avail yourself of the benefits of your OPD coverage, there are two different ways of doing so. You can either opt for cashless treatment or go for reimbursement claims. Here are more details about each claim type.

Cashless claim
In this type of claim, the insured must visit a network hospital as listed by the insurance provider. Upon visiting a network hospital, the insured can show their insurance card and benefit from cashless benefits. In simple words, your insurance provider will take care of all the expenses and will settle them directly with the hospital. Thereby, ensuring that you do not have to worry about spending anything out of your pockets.

Reimbursement claim
A reimbursement claim is the other type of claim that an insured can opt for. In such claims, the insured must undergo the treatment at their expense. Later, on submitting all the necessary documents, the insurance provider will reimburse all the expenses. Documents usually include lab diagnostic reports, consultations with doctors, medical prescriptions, recommendations for dental treatment, etc.

Difference between daycare treatment and OPD treatment

OPD or outpatient department treatment is often confused with daycare treatment. And a lot of people use the terms interchangeably. However, that is not the case.

Daycare treatment refers to any medical procedure or attention that a person needs, which requires them to be admitted to the hospital for at least one day or 24 hours. Usually, the treatments require the patient to be under general or local anaesthesia. Minor accidents or health ailments require daycare treatment. Some common examples of daycare treatments are dialysis treatment, radiation treatment, etc.

While both daycare and OPD treatments require much less time as compared to inpatients, however, they are quite different. In order to avail of OPD treatments, a patient is not required to be admitted to the hospital. However, for daycare treatments, they must be admitted for at least 24 hours.

Here is a simple example to demonstrate the difference between both treatments to help you understand them better.
Patient A has severe stomach pain and visits a doctor for consultation. The doctor on examining, prescribes some medicines and recommends a couple of days rest for Patient A. After the consultation, Patient A can return home and take the medicines and rest as prescribed.

On the other hand, if Patient A had met with an accident that resulted in a fracture, he or she would need to visit the doctor for treatment of the fracture. It is possible that the patient would need to be under observation for a day. If the patient is admitted for more than a day, they would qualify as an inpatient.

Difference between Out-patient department treatment and in-patient department(IPD) treatment

OPD and IPD are two entirely different types of treatment. IPD or indoor patient department treatment refers to all the medical attention that a patient receives while being admitted to the hospital. IPD admissions are usually done on the recommendation of a doctor. The patient can be admitted from OPD, ambulatory care, or even emergency services.

IPD treatment needs much higher levels of care, where the patients are monitored by doctors regularly, nursing services are available, and drugs or medications are administered as required. Some common departments that might require IPD treatment include orthopaedics, general surgery, general medicine, ophthalmology, physiotherapy, burn cases, etc.

Here are a couple of examples where a patient might be admitted to the hospital for IPD treatments. Patient A meets with a severe accident while driving. He is first moved to the emergency department, receives all the immediate care, and is later moved to IPD for further treatment and recovery.

The parent of an insured has been suffering from arthritis for a while and they need knee replacement surgery. For the surgery and recovery, they would need to be admitted to the IPD, undergo surgery in the operation theatre, and return to bed for further recovery.

A couple of major differences between OPD and IPD treatment include the duration of stay and the kind of services on offer. For a visit to qualify as IPD, the patient must be admitted for more than 24 hours to the hospital. On the other hand, for OPD treatments, the patient can leave home within a few hours.

Also, in IPD treatments patients receive much better care, due to much more serious conditions. As a result, the cost of treatment is high as well.

List of top 5 health insurance plans with OPD cover

The following is a list of the top 5 health insurance plans that you can buy right now, that offer OPD cover. Here are the plans along with their policy highlights to make the decision easier for you.

1. SBI Arogya Plus
The plan offers OPD cover for its subscribers and the sum insured ranges between Rs. 1 lakh and Rs. 3 lakhs. SBI’s Arogya Plus will let you get treatment coverage as well.

2. Bharti AXA Health AdvantEdge
The plan offers a wide range of sums insured. Starting at Rs. 2 lakhs the plan offers coverage for up to Rs. 3 crores, depending on what you are looking for. OPD cover is optional with the plan, providing you with a robust health plan.

3. Bajaj Allianz Tax Gain
The plan grants you access to more than 6,000 network hospitals in the country. You can avail of hospitalisation and OPD expenses under a single plan. The plan also covers daycare procedures, offering you a rounded policy.

4. Aditya Birla Activ Health Enhanced Platinum
Aditya Birla’s plan also offers a wide spectrum of sums insured for you to choose from. The sum insured ranges between Rs. 2 lakhs and Rs. 2 crores. The coverage for OPD ranges between Rs. 5,000 to Rs. 20,000.

5. Care Family Health Insurance Plan
If you are looking for an ideal plan for your entire family, Care’s Family Health Insurance Plan is just ideal. The sum insured on the plan ranges between Rs. 3 lakhs and Rs. 6 lakhs. The OPD cover on the plan is optional and ranges between Rs. 5,000 and Rs. 50,000.

How to file a claim for OPD cover?

If you want to file a claim for OPD cover, there are a couple of ways to do so. And the steps will vary accordingly.

1. Cashless:

  1. For cashless claims, you can visit any of the hospitals under the network of an insurance provider.
  2. Once you reach the hospital for treatment, you can share your insurance policy card.
  3. You can avail of the OPD services.
  4. Your insurer will directly settle the bills with the hospital.

2. Reimbursement:

  1. For reimbursement claims, you can visit any hospital of your choice.
  2. You must first avail of the OPD treatment first.
  3. Inform your insurance provider regarding the intent to file a claim.
  4. You can file a claim on their app, or website or by calling the insurance provider.
  5. You must submit all the necessary documents such as bills, consultation notes, summaries, etc.
  6. A lot of insurers will allow you to submit the documents online.
  7. Once the claim is approved, the amount will be credited to your account.

To Sum Up!

Always assess your situation and buy an OPD cover with a good insurance provider. This reduces any financial stress in case of a medical emergency and this also ensures you get the best treatment available without compromising on doctors and the treatment due to high costs. So do not delay and get OPD coverage and enjoy a happy life with no stress on this front.

Leading Health Insurance Companies

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care health insurance

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