1. Home
2. Blogs

OPD Cover in Health Insurance: Benefits & Guide

• 
• 
• 
• 0
• 0

Do you end up spending a lot on hospital visits? OPD expenses are quite common when you go for minor treatments, routine check-ups or simple tests. Even though you don’t need to be hospitalised, costs like doctor consultations, diagnostic tests and pharmacy bills can add up quickly. To avoid this extra financial burden, it is smart to choose a health insurance plan that includes OPD coverage. Read on to learn what is OPD coverage in health insurance, its benefits and more.

What is OPD Cover in Health Insurance?

OPD stands for Outpatient Department. It refers to medical care you get without being admitted to a hospital. An OPD cover in your health insurance helps you pay for medical needs that don’t require hospitalisation. Here’s what it usually includes:

1. Doctor consultations:

Whenever you visit a doctor, whether it is a general physician, a specialist or just a follow-up, your OPD cover can help pay for the consultation. The insurer may either settle the bill directly or reimburse you later.

2. Diagnostic tests:

If your doctor recommends tests to understand your health better, OPD cover usually helps with those expenses too. This may include:

• Blood tests

• X-rays

• Ultrasounds

• CT or MRI scans

• ECG, EEG

• Endoscopies (like colonoscopy or gastroscopy)

• Biopsies

OPD cover typically includes most diagnostic tests that help doctors identify or confirm a medical condition.

3. Minor medical procedures:

Some treatments don’t require hospital admission, and OPD cover can help pay for these small procedures. This may include things like:

• Stitching cuts

• Minor wound care

• Basic dental work

4. Medicines and pharmacy bills:

If your doctor prescribes medicines, whether for a short-term illness or a long-term condition, your OPD cover can help you with the cost of those pharmacy bills.

5. Alternative therapies:

Some health insurance plans also cover non-traditional treatments such as Ayurveda, homoeopathy, acupuncture and chiropractic sessions.

Remember, coverage can differ depending on the insurer and the plan.

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 enthusiasts 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.

Factors to Consider While Buying OPD Health Insurance Plans

Here are some key factors to consider when buying OPD health insurance plans:

1. What’s covered:

Check what services are included, like doctor consultations, diagnostic tests and medicines. Ensure it aligns with the type of healthcare you are likely to require.

2. Extra premium for OPD coverage:

Check how much more you will pay for OPD coverage and decide if it is worth it for you.

3. Insurer’s network of hospitals and clinics:

Check if the insurer has a wide network of hospitals and clinics where you can use cashless OPD services. This makes visits easier and less stressful.

4. Caps and sub-limits:

Some plans have caps on certain tests or treatments. Knowing these limits helps you avoid surprise expenses.

5. How claims work:

Check how to make a claim or use cashless services. A smooth process makes it quick and easy to avail of treatment.

6. Waiting periods:

Certain services may not be covered right away, so it is important to check the waiting periods in advance and plan your care accordingly.

7. Exclusions:

Check what the plan excludes so you don’t get any surprises when claiming.

Difference Between OPD Treatments and IPD Treatments

Here are some differences between OPD and IPD treatments:

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. Early diagnosis can significantly aid in the treatment of many ailments. Individuals with chronic conditions can utilise this coverage for regular health monitoring. OPD cover also makes the whole process convenient for patients, as it allows them to access cashless services in a network hospital. Lastly, along with peace of mind, it also offers tax benefits under Section 80D of the ITA.

Documents Required to File a Reimbursement Claim Under OPD Health Insurance

The following documents are required to file a reimbursement claim under OPD health insurance:

• Original copy of the claim form, duly completed and signed

• Consultation bills and doctor visit papers

• Prescriptions from the doctor for consultations

• Diagnostic test bills and reports (e.g., lab tests, scans)

• Medicine/pharmacy bills, along with the doctor’s prescription for the medicines

• Proof of identity (such as Aadhaar card, PAN card, passport)

• Proof of age (such as birth certificate, passport or other age document)

• Address proof (such as utility bill, Aadhaar card, passport)

• KYC documents for identity and address verification

• Medical reports, if applicable (like test reports and other supporting medical documentation)

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

Many insurance providers are 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 enable you to make a well-informed decision. Typically, purchasing such a plan from an insurer with a strong market reputation is the best option.

Conclusion

OPD cover in health insurance helps you manage everyday medical expenses, such as doctor visits, tests, and medicines, without straining your budget. By knowing the benefits, costs and terms of your policy, you can pick a plan that fits your healthcare needs. Whether it is regular check-ups or minor treatments, OPD coverage makes healthcare simpler and more affordable.

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.

4. Which health insurance covers outpatients?

For OPD coverage, you need a health insurance plan that includes OPD (Out-Patient Department) benefits. This covers doctor visits, tests and medicines without hospital admission. Many insurers offer OPD add-ons or special OPD plans. However, it is important to check the policy to confirm it is included.

5. Can I buy OPD health insurance online?

Yes, you can buy OPD health insurance online. You can easily compare plans from different insurers to choose the one that best fits your healthcare needs.

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

RELATED ARTICLES

How OPD Cover in Health Plans Can Cut Your Costs

Why Health Insurance with OPD Cover Gaining Popularity?

IPD vs OPD Treatment: Know the Difference

OPD Cover for Senior Citizens Made Simple

Difference between OPD and Day Care Treatment

---

• 
• 
• 
•