OPD Cover in Health Insurance: Benefits & Guide

Posted on: Dec 5, 2023 | 3 mins | Written by: HDFC ERGO Team

OPD Cover in Health Insurance: Benefits & Guide

Outpatient Department (OPD) expenses are quite common when you visit the hospitals for minor treatments, regular check-ups, simple procedures, etc. Though these visits may not require you to be hospitalised, they can still require you to spend a lot out of your pocket. Pharmacy charges, doctor’s consultations, diagnostic tests, and other expenses are examples. To reduce this financial burden, it is always wise to have health insurance plans with OPD coverage.

Common OPD Procedures

Some common OPD procedures which are covered in OPD plans are listed below:

• Eye procedures

Several procedures relating to the eyes, such as cataracts, glaucoma, chalazion, and laser treatments like photocoagulation, may be covered in OPD plans.

• Skin procedures

Some skin treatments can be done in OPD without getting admitted to the hospital. These are acne removal procedures and laser therapies designed to reduce wrinkles, scars, and other skin imperfections.

• Mouth and nose procedures

Tonsillectomy or removal of tonsils, removal of nasal polyps, and treatment of certain mouth and nose infections are common OPD procedures, and their expenses can be claimed from your insurance provider if you have OPD coverage.

• Meniscus procedure

The meniscus acts as the knee's shock absorber. If you have a meniscus tear, a surgeon can provide the necessary treatment in OPD. This is quite common among sportspersons or those who exercise regularly in the gym.

OPD Cover with Health Insurance Benefits

• Covers expenses related to medicines, diagnostic tests, and doctor consultations.

• The policyholder can claim multiple times as and when the expenses are incurred.

• Covers multiple types of expenses, such as contact lenses, hearing aids, crutches, dentures, spectacles, etc., which are not covered in the regular healthcare plans.

• Covers regular doctor consultation fees even for simple ailments like viral fever.

• Offers coverage for preventive care services, like routine health check-ups, screenings, and vaccinations

• Some insurance providers offer cashless treatment for OPD procedures with an additional premium.

• Beneficial for those with chronic medical conditions like diabetes, arthritis, asthma, etc., requiring regular medical attention.

• The insured can claim a tax deduction under Section 80D for the premium paid towards OPD cover.

Who Should Get a Health Insurance Plan with OPD Cover?

1. People between the age group of 25-40 years

People in this age group are more likely to use OPD services rather than in-patient hospitalisation. Due to their strong immunity, they are less likely to fall severely ill, requiring admission to a hospital. Therefore, it makes sense for them to purchase OPD coverage to stay financially protected against costs incurred for doctor consultations, medicines, lab tests, and other related expenses. Buying health insurance early also has benefits, like lower premiums because insurers consider such policyholders to be low-risk. Policyholders can also complete the waiting periods early and avail of tax benefits on health insurance premiums.

2. Fitness enthusiasts

Although fitness freaks are less likely to fall sick, they can still suffer workout-related injuries, which are treated in the OPD. Buying OPD cover is a wise option as it will provide financial protection in such cases.

3. Senior citizens

It is recommended that senior citizens opt for an OPD cover in health insurance due to their vulnerability to illnesses and infections, as well as the need for frequent medical consultations. Due to age and low immunity, they may undergo minor surgeries and other OPD treatments like dental procedures. An OPD cover will help ease their financial burden by covering all the OPD expenses. A senior citizen health insurance plan with OPD cover will give them comprehensive coverage.

4. Employees with limited group health insurance coverage

If your group health insurance doesn't have adequate coverage, buying an additional personal healthcare plan for better protection is advisable.

Difference Between OPD Treatments and IPD Treatments

Here are some differences between OPD and IPD treatments:

OPD (Out-Patient Department)	IPD (In-Patient Department)
Patient does not get admitted to the hospital for more than 24 hours	Patient has to be admitted for more than 24 hours
Services include doctor consultations, diagnostic tests, routine check-ups, minor surgeries and procedures	Severe medical conditions which need intensive care and treatment
Patients can leave after a few hours of receiving treatment in case of minor procedures	Patients have to stay in the hospital for the duration of the treatment, which can be for a few days
Covers routine check-ups, lab tests, minor procedures, etc.	Covers in-patient, pre- and post-hospitalisation expenses

How Does OPD Cover Work in Health Insurance?

An OPD cover reimburses the medical expenses you pay towards outpatient charges. You can submit the relevant documents (including bills, receipts, prescriptions, etc.) to your insurance service provider to claim this benefit, in case of reimbursement claims. If your OPD cover is part of a cashless claim, the process is quite simple. The insurance provider will pay the amount directly to the hospital, thereby saving you time and effort.

It is wise to know the inclusions and exclusions before investing in a health insurance plan with OPD coverage.

Eligibility and Limitations of OPD Cover in Health Insurance

Whether you invest in individual plans, group plans, or family health coverage plans, it is essential to be fully aware of the OPD coverage terms of your policy to receive the full benefits. The main eligibility criterion to claim this cover is that the treatments/procedures shouldn’t require overnight hospitalisation. Expenses involving doctor’s consultation, diagnostic procedures, vaccination, routine checks, medicines, physiotherapy and other minor treatments are usually eligible to be claimed as part of your policy’s OPD coverage.

However, there are certain limitations or exclusions of the OPD cover, which mostly involve the following:

• Expenses towards treatments/procedures that require hospitalisation

• Daycare treatments (even if they don’t need 24-hour hospitalisation)

• Expenses for self-harm injuries

• Cosmetic treatments and plastic surgeries

• Treatments not prescribed by doctors

• Experimental treatments not backed by proper scientific evidence

• Weight loss treatments/surgeries

• Treatments related to substance or alcohol addiction

• Pre-existing diseases (at least until the waiting period is over)

What is the Claim Settlement process for OPD Expenses?

There are two ways you can claim OPD expenses:

1. Cashless claim

Cashless claims can only be availed of at network hospitals of the insurance provider. After your OPD consultation or treatment, show the insurance card or policy number at the hospital insurance desk and fill out the claim form. The hospital will then settle the bills directly with the insurance provider, and you do not need to worry about paying anything upfront except the deductible amount. However, you must inform the insurer at least two days before the consultation to avail of cashless health insurance.

2. Reimbursement claim:

In a reimbursement claim, you have to first make the payment following the OPD treatment and then file the claim. You need to fill out the claim form and submit it to the insurance provider along with required documents like bills, prescriptions, lab reports, etc. After the claim is verified and approved, the claim amount will be credited to your account. For a reimbursement claim, you can get treated in any hospital.

Why Should You Opt for an OPD Cover with Medical Insurance Plans?

There are many benefits of choosing health insurance plans with OPD coverage. This cover adds more value to your health plan and improves your healthcare experience. To begin with, it helps you save money spent on Outpatient Medical Expenses, thus significantly reducing your financial burden. It also encourages you to prioritise your health as you are no longer worried about doctor consultations, lab tests, and pharmacy bills and won't hesitate to go for a check-up. As you know, early diagnosis can help in the treatment of many ailments. People with chronic conditions can use this cover for regular health monitoring. OPD cover also makes the whole process convenient for patients because, in a network hospital, patients can get cashless services. Lastly, along with peace of mind, it also offers tax benefits under Section 80D of the ITA.

How to Choose an OPD Cover for Your Health Insurance Plan?

Begin by comparing the options available to you. There are many insurance providers offering different plans with varying premiums. You should opt for a cover that suits both your needs and budget. You can easily compare these plans online, either by going to different insurer websites or an aggregator app. Additionally, the cover should provide access to a wide network of hospitals, enabling you to utilise cashless facilities. Don't forget to read the terms and conditions to ensure a fair deal. Thorough research will help you make a well-informed choice. Usually, buying such a plan from an insurer with a good market reputation is the best option.

Conclusion

Minor injuries or ailments that look harmless initially should not be ignored. With OPD coverage by your side, you shouldn't worry about the expenses. Now that you are aware of how the best health insurance with OPD cover can help you and the process of finding the best plan, all that remains is to start analysing how it ties well with your current insurance plan. Always feel free to discuss your insurance needs with the insurer or switch to one offering a better deal.

Also, to get an idea of how much you need to pay for health insurance, you can use online tools for calculating health insurance premiums and choosing a policy that fits your requirements and budget.

FAQs

1. Does the standard health insurance policy cover OPD expenses?

For claiming OPD expenses, you have to buy an OPD add-on cover along with your health insurance policy by paying an additional premium. However, some insurers bundle OPD with your base health insurance plan. So, it’s advisable to check with your insurer.

2. Can I claim tax benefits on health insurance plans with OPD cover?

Yes, you can claim tax deductions on health plans with OPD cover under section 80D of the Income Tax Act.

3. What are the factors to consider while buying OPD cover?

Some factors to consider when buying an OPD cover include the scope of coverage, benefits, waiting periods, exclusions, claim process, and network hospitals. You need to pay an additional premium for this add-on cover.

Disclaimer: The above information is for illustrative purposes only. For more details, please refer to the policy wordings and prospectus before concluding the sales.

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