health insurance: Should you buy a health insurance policy with OPD cover? – The Economic Times

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In hospital parlance, OPD stands for Out-Patient Department. OPD treatment refers to consultation with doctors and treatments that can be done with the doctor or medical practitioner’s advice without getting admitted in the hospital.

You can buy a health insurancepolicy with OPD cover if you think that you might incur healthcare costs which do not require in-patient hospitalisation.

The Out-Patient Department (OPD) cover under a health insurance policy allows you to make claims for any expenses incurred on medical consultation/treatment not requiring hospitalisation. However, you must know that these insurance policies generally allow you to file a claim only for OPD treatments taken in network hospitals.

Here is a closer look at health insurance policies that come with OPD cover. We will examine the premium costs of these policies, what is covered and what is not, and how claims are settled.

What is OPD treatment?
In hospital parlance OPD stands for Out Patient Department. OPD treatment refers to consultation with doctors and treatments that can be done with the doctor or medical practitioner’s advice without getting admitted in the hospital. Traditionally mediclaim or health insurance policies do not cover most OPD treatments/consultations with a few exceptions.

OPD cover in health insurance
Amit Chhabra, Head-Health Insurance, said, “Health insurance policies that offer OPD cover help the insured claim expenses other than those incurred during hospitalisation. The term OPD expenses refers to expenses incurred for a visit to a clinic or a hospital or an associated medical facility for diagnosis and treatment based on the advice of a medical practitioner. On these visits, the patient does not need to be admitted in the hospital as day-care or in-patient. Some common OPD expenses include Doctor’s Consultation Charges, lab tests, cost of medicines, dental treatments, fractures, dentists visit, paediatrician visits etc.,” Chhabra said.

What is not covered under OPD?
“Inpatient treatment, daycare procedures and naturopathy treatments are not covered under OPD expenses. Besides, cosmetic treatments and self-inflicted injuries are also not covered,” said Chabbra. Ofcourse, hospitalisation expenses, which are traditionally covered by health insurance policies, do not fall under OPD category.

Health insurance policy premium with/without OPD cover
Premium mentioned below is of an individual male who is 35 years old with a sum insured of Rs 10 lakh

Insurance plan
Policy premium per annum (with OPD cover; in Rs)
Policy premium per annum (without OPD cover; in Rs)
Star Health Insurance
Max Bupa

Source:; As on October 9, 2020

Don’t get confused between OPD treatment and daycare treatment

As mentioned above, OPD treatment refers to visiting a clinic or a hospital or an associated facility for diagnosis and treatment (of a health issue) based on the advice of a medical practitioner and does not require hospitalisation. . On the other hand, daycare treatment includes procedures that require hospitalisation but for less than 24-hours. These include chemotherapy, radiation, dialysis, cataract, lithotripsy, and tonsillectomy.

OPD expenses claim settlement process
Rakesh Goyal, Director Probus Insurance, Online Insurance Broking firm said, “For the claim process, the expenses can be claimed after the required documents are submitted in case of OPD treatment.” Generally, you need to submit OPD consultation prescription, prescription for medicines, duly filled claim form to the insurer for claim settlement.

There are few other things that you need to know about the claim settlement procedure. Goyal said, “You must check the number of times claims can be made for OPD expenses. Also, whether you can claim OPD expenses without a long waiting period. The extent of OPD coverage may vary from insurer-to-insurer, hence it is advisable to read the policy document and understand the terms and conditions before opting for this cover.” Ofcourse, the amount insured under OPD cover or the maximum amount you can claim as OPD expenses in one policy period should also be checked and evaluated as to whether it is enough or not.

Should you buy health policy with OPD cover?
Experts say that OPD health insurance policies vary from insurer to insurer and unfortunately these do not offer uniform benefits. For instance, in some products only vaccinations are covered, while in others you may be restricted to using only certain hospital networks or specific pharmacies. Some policies restrict you to a single claim filing or a fixed number of claims in a year. Then few policies do offer comprehensive OPD cover.

So, should you get such a cover? Chandan D. S. Dang, Executive Director,, a Delhi-based online insurance broking firm, says that benefits of such a cover are rather limited. Here is why: “The OPD health policies available today provide limited insurance cover. For instance, you may have to pay an additional Rs 7,000 (plus GST) to get an OPD cover of Rs 10,000 cover and that too may have a deductible component built-in. Hence, given that the covers are usually priced at 70-80 per cent of the maximum claim, and the claim process can be cumbersome, getting an OPD cover may not be very beneficial.”

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