OPD Cover in Health Insurance: Coverage & Eligibility Criteria of an OPD Cover
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Not all diseases require hospitalization. There are certain ailments for which treatments only require consultations, diagnosis and any treatments without a stay in the hospital. The Outpatient Department or OPD includes all such treatment variables.
In India, various insurance companies offer OPD cover health insurance to policyholders as financial coverage against such types of treatments that do not require hospitalization. In short, medical insurance with OPD covers include expenses incurred outside of in-hospital treatment.
Table of contents
- Why is OPD Cover Health Insurance Necessary?
- Who Should Invest in an OPD Cover Health Insurance Policy?
- What are the Benefits of OPD Coverage?
- Medical Insurance with OPD Cover Benefits – Eligibility
- OPD Cover Health Insurance: Inclusions
- Difference between Day Care Treatment and OPD Cover
- What is Not Included under OPD Cover?
- Claim Settlement Process under OPD Cover
- Difference between OPD Treatment and In-patient Department
- How to Buy OPD Coverage Health Insurance?
- Final Words
- FAQs on OPD Cover Health Insurance
Why is OPD Cover Health Insurance Necessary?
Purchasing health insurance that covers OPD expenses is necessary for the following reasons:
Increasing need
Our lifestyle and way of living is constantly evolving. This change has led to the prevalence of various illnesses and chronic ailments requiring long-term care. Thus, it is essential to purchase health insurance with OPD benefits. This cover will help to take care of regular medical expenses.
OPD costs contribute to most of the total healthcare costs
Outpatient department costs account for 62% of total healthcare costs. So, a cover against these medical expenses is beneficial.
Who Should Invest in an OPD Cover Health Insurance Policy?
Given below are the category of people who should invest in an OPD health insurance policy:
- Patients who need to visit hospitals very frequently for check-ups.
- People with pre-existing health conditions that require frequent medical consultations.
- Patients suffering from diabetes, asthma, thyroid should invest in an OPD health insurance policy as they need to visit a hospital for regular check-ups.
- OPD health insurance policies cover pharmacy expenses so it’s ideal for people who need to buy medicines regularly.
- Patients who are immunocompromised should invest in OPD health insurance policy.
Also Read: What Is Domicilary Hospitalisation: Coverage, Exclusions And How To Claim And Documents Needed
What are the Benefits of OPD Coverage?
The specific benefits of this plan are as follows:
Additional coverage
When you purchase an insurance plan including an outpatient expense cover, you get extra protection that provides financial coverage against daily medical expenses.
Some insurers offer a cashless scheme to cover treatments undertaken at the outpatient department. This makes your claim process smooth and eases off cash crunches arising during medical treatments.
Sum insured
A sum insured amount gets determined based on the policyholder’s age for plans with OPD cover health insurance. In a floater policy, the eldest member’s age gets considered.
Greater tax reliefs
Health insurance plans covering OPD expenses provide greater tax exemption on the premium amount. In addition to this, there will be no tax deduction at the source for claims.
Multiple claims possible
With this cover, you can claim your expenses multiple times.
Pharmacy bills covered
Your pharmacy bills will get covered under such a health insurance plan. This means if you purchase medicines, you can get the same reimbursed.
Covers a wide variety of expenses
Expenses such as crutches, spectacles, contact lenses, hearing aid, and many others get covered under such a health scheme.
Carry forward benefit
Certain insurance service providers allow you to carry forward a fixed portion of an unutilized sum insured amount in a specific policy period.
Medical Insurance with OPD Cover Benefits – Eligibility
There is no specific eligibility norm when it comes to availing outpatient department benefits. Anyone unwell can visit their nearest clinic and avail of medical treatment. A policyholder can then claim expenses under this healthcare scheme.
If you are eligible to purchase a particular health insurance policy with an outpatient cover, you can utilize the benefits.
OPD Cover Health Insurance: Inclusions
Following are the expenses covered under an outpatient department cover:
- Doctor’s fees or any other consultation fees
- Diagnosis costs like X-ray fees
- Crutches and wheelchair
- Routine check-up
- Vaccination
- Minor surgeries and dressing
- Dental treatment expenses
- Hearing aid
- Spectacles and contact lenses (covered by specific plans)
Difference between Day Care Treatment and OPD Cover
The differences between day care treatment and OPD are given below:
| Day Care Treatment | OPD |
| Day care treatments require hospitalisation, i.e., the patient has to stay at the hospital for a few hours | One doesn’t have to get hospitalised for OPD treatments |
| Many insurance companies cover day care treatments | Insurance policies don’t generally cover OPD treatments but one can opt for OPD health insurance policies |
| An example would be Lasik cataract procedures | Examples would include consulting a doctor for a vital fever or root canal treatment |
What is Not Included under OPD Cover?
Find all the exclusions as listed below:
- Expenses of cosmetic treatment
- Physiotherapy
- Thermometers and BP monitors
- Supplements
- Vitamins
- Dietician fees and consultation
Claim Settlement Process under OPD Cover
The important types of claim settlement process under OPD cover are detailed as follows:
Steps to follow for Cashless Claims:
Step 1: Visit a network-hospital
Step 2: Display the policy card and avail the OPD treatment
Steps to follow for Reimbursement Claims:
Step 1: After you have availed of the OPD treatment, contact the insurer and submit the relevant documents including the medical bills
Step 2: Many insurance companies allow people to submit documents for reimbursement online via their accounts as well
Also Read: Understanding Health Insurance Claim Settlement Ratio In India
Difference between OPD Treatment and In-patient Department
The table given below provides the differences between OPD and In-patient Department treatments:
| OPD Treatment | IPD Treatment |
| Patient does not have to get hospitalised | Patient gets hospitalised for more than 24 hours |
| It involves the initial or subsequent medical consultations where the doctor checks, diagnoses and sets a treatment plan | After the consultations, if the doctor feels that the patient requires hospitalisation, he/she recommends IPD treatment |
| Examples would include medical consultations, ophthalmic procedures, minor surgeries | Examples would include gall-bladder operation, childbirth, rehabilitation |
How to Buy OPD Coverage Health Insurance?
Follow these simple steps to purchase a health insurance policy with OPD cover:
- Select a health insurance plan with OPD cover online from a reliable insurer.
- Enter details such as name and contact information. While choosing an insurer, you will find a ‘Get Quote’ option on the screen. Click on it to find details of your plan premium and more.
- In case you have any pre-existing diseases or are on medications, confirm it in this step.
- Choose the policy sum insured, tenure, add-ons and other details as required.
- You must compare the premiums before settling for one that is under your budget.
- After paying the premium online from the payment gateway, the policy will be issued, and the details will be mailed to you.
Final Words
Medical insurance with OPD cover helps boost the scope of coverage under insurance policies further. Through this scheme, policyholders can take care of their daily medical expenses, as mentioned above. With a growing rise in basic medical expenses such as consultation fees, diagnosis fees, and more, this healthcare policy can be extremely beneficial for any family.
To avail of an OPD cover under your health insurance policy, turn to Navi health insurance. Download the Navi App today to enjoy an instant paperless application process!
FAQs on OPD Cover Health Insurance
Ans: It varies from one insurance provider to another. Many insurance companies have set the OPD coverage amount at a specified limit. People should check the specified OPD expenses for each medical insurance policy before selecting the one which is most suitable for them.
Ans: Daycare treatment and OPD expenses are considered different. So, daycare treatments do not fall under OPD cover. Importantly, daycare treatments are covered by most health insurance policies. But it is not the same with OPD expenses. This is the reason why it is advisable to opt for OPD health insurance policies.
Ans: An outpatient department expense is included under the sum insured limit. Any outpatient expenses are deductible from your coverage amount.
Ans: The waiting period for claiming an OPD expenses is about 90 days.
Ans: Yes, you can get tax relief under outpatient care.
Ans: Insurers usually offer this scheme under any specific health insurance plan as an add-on.
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Disclaimer: This article has been prepared on the basis of internal data, publicly available information and other sources believed to be reliable. The information contained in this article is for general purposes only and not a complete disclosure of every material fact. It should not be construed as investment advice to any party. The article does not warrant the completeness or accuracy of the information, and disclaims all liabilities, losses and damages arising out of the use of this information. Readers shall be fully liable/responsible for any decision taken on the basis of this article.
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