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IPD Vs OPD in Health Insurance

May 26, 2024


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IPD Vs OPD in Health Insurance

IPD vs OPD in Health Insurance: An Overview

In health insurance, it is important to understand the difference between In-Patient Department (IPD) and Out-Patient Department (OPD) coverage for Health Insurance as it helps in making informed decisions about your healthcare needs. IPD and OPD services cater to different aspects of medical care, and their Insurance Coverage and Claim Processes vary accordingly.

This article will explore the differences between IPD and OPD Coverage, implications on Health Insurance Coverage and Claims Processes.

What Is OPD? – OPD Full Form

The full form of OPD is Outpatient Department. OPD is a hospital department where patients receive healthcare services without getting admitted.

The Outpatient Department of a Hospital provides consultations, minor surgical and diagnostic procedures, follow-ups, and treatments that do not necessitate hospital admission. Specifically, OPD services are not confined to hospital premises and can be accessed at clinics, consultation rooms, and even virtually. OPD Services are usually used for minor illnesses, injuries or routine check-ups. Outpatient Departments also provide Emergency Medical services.

IPD vs OPD in Health Insurance

Outpatient Departments are an important component of the healthcare system as they reduce the burden on hospitals. Additionally, they are more cost effective for the patient as well since hospital stays are comparatively more expensive.

Does Health Insurance provide cover for OPD Treatments?

Some Health Insurance Plans do offer cover for OPD Treatments. OPD Cover in a Health Insurance Policy pays for the cost of Outpatient Treatment. Health Insurance Plans with OPD Cover do not require the patient to be admitted to the hospital as an Inpatient.

Health Insurance Plans with OPD Cover typically provide cover for the following expenses.

  1. Doctor’s Consultation Fees for visits to physicians or specialists
  2. Diagnostic tests like Blood Tests, X-rays, and Ultrasounds
  3. Prescribed medications for outpatient treatment
  4. Health Check-Ups
  5. Minor surgical procedures that don’t require hospitalization

However, Health Insurance Policies with OPD Cover may have sub-limits or caps on coverage for specific services. Co-payments or Deductibles may also apply, where the policyholder shares a portion of the costs. It’s essential to review the Policy Terms and Conditions carefully to understand the Coverage, Exclusions, and any applicable limits.

What are the Benefits of OPD Treatment Coverage in Health Insurance Policies?

OPD Expense Coverage in a Health Insurance Plan provide the following benefits:

  1. It is useful for people who require frequent visits to doctors for routine ailments like Diabetes, Asthma etc.
  2. OPD Coverage provides reimbursement for Pharmacy Bills
  3. Diagnostic Tests are also covered under OPD Coverage

What Is IPD – IPD Full Form?

The full form of IPD is Inpatient Department. IPD is a hospital department where patients receive treatment by getting admitted to the hospital for more than 24 hours. Patients requiring IPD services need to undergo formal hospital admission. IPD Services are typically for more severe medical conditions that require close monitoring, surgeries and cannot be treated by the OPD Department.

What Does IPD Insurance Cover?

IPD (Inpatient Department) Insurance covers medical expenses when the patient needs to be admitted to a hospital for a minimum of 24 hours. Here are some common aspects covered by IPD insurance:

  1. Hospitalization Expenses
  2. Surgical Expenses
  3. Pre and Post Hospitalization expenses
  4. Doctor Visit Charges, Surgeon Charges
  5. Diagnostic tests
  6. Pharmacy Bills
  7. Operation Theatre Charges
  8. Room Rent and ICU Charges
  9. Ambulance Services

It’s important to note that the patient needs to be admitted to the hospital for a minimum of 24 hours so that the IPD Health Insurance Policy can pay out the Insurance Claim.

Also, specific coverage and limits of IPD Insurance Policies may vary depending on the insurer and the chosen plan. It’s always advisable to carefully review the Policy Wordings to understand the inclusions, exclusions, sub-limits, and any other terms and conditions.

Differences Between OPD And IPD

Understanding the distinction between OPD and IPD treatments is crucial, particularly when selecting an appropriate Health Insurance Policy. Here are the key differences:

Aspect OPD Insurance IPD Insurance
Coverage Type This Insurance covers expenses incurred for outpatient medical services, including doctor consultations, diagnostic tests, and medication costs. This insurance covers in-patient hospitalization costs, including room charges, surgeries, and treatments requiring an overnight stay of at least 24 hours, along with daycare treatment.
Types of Expenses Covered 1. Doctor’s consultation fees 2. Diagnostic tests 3. Medications 4. Preventive Care Treatment Expenses Room Rent and ICU Charges Surgical Costs Pharmacy Bills Doctor Visit Charges, Surgeon Charges Operation Theatre Charges Disagnostic Tests Pre and Post-Hospitalisation Expenses
Claim Process Reimbursement Claim Process Cashless and Reimbursement Claim Process available
Typical Examples Regular check-up with a general practitioner Dental check-up and cleaning Cataract Knee replacement surgery
Coverage Limitations Frequently imposes limits on the number of visits or the total reimbursement amount per year for each service type (e.g., ?20,000 annually). Coverage limits may fluctuate depending on the sum insured, with potential sub-limits for specific expenses like room rent and disease-specific limits.
Waiting Period Generally, there is no waiting period. IPD insurance may have various waiting periods for Pre-Existing Diseases, Maternity Coverage etc.

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Claims Process for IPD and OPD Treatments

OPD Claims Process

OPD Claims work mostly on Reimbursement Basis. Here is a step-by-step guide for OPD Claims:

  1. Service type: Outpatient services such as doctor visits, diagnostic tests, small procedures, and prescription drugs, are covered by OPD Insurance.
  2. Billing Payment: The Patient availing the OPD Treatment pays the bill for the OPD Treatment availed and collects an invoice for the services provided during an outpatient visit. In addition, the patient also needs to collect all the relevant documents such as Diagnostic Reports, Prescriptions etc.
  3. Document Submission: The patient submits the bills and relevant documents such as Diagnostic Reports, Prescriptions etc. to the Insurance Company for reimbursement along with other Documents such as ID Proof, Bank Account Details and Duly filled and signed Claim Form
  4. Reimbursement: The Insurance Company will reimburse the bills to the bank account of the Insured for an admissible Claim in accordance with Policy Terms and Conditions.

IPD Claims Process

IPD Claims are covered by the Insurance Company in 2 ways - Cashless and Reimbursement. The Cashless and Reimbursement Claims Process are explained in detail below:

IPD Cashless Claim Process:

In order to avail Cashless Claim Settlement under the IPD Health Insurance Policy, the Policyholder must follow the steps listed below:

  1. Locate the nearest network hospital covered by the Health Insurance Policy to avail treatment.
  2. Inform the Insurance Company about the hospitalization before 3-4 days in case of a planned hospitalization and within 4-5 hours in case of an emergency
  3. Show the Health Card issued by the Insurance Company to the Insurance desk at the hospital
  4. Fill the Claim Form provided by the hospital
  5. The Hospital sends the Claim Form to the Insurance Company for Claim Settlement along with all the other relevant documents
  6. The Insurance Company will inspect the details and inform the Insured about the approval or rejection of the Claim
  7. Once the Claim gets approved, the hospital sends the expenses and receipts to the Insurance Company and the hospital gets reimbursed for the treatment expenses directly by Insurance Company.

IPD Reimbursement Claim Process

If the Policyholder chooses a non-network hospital, he will have to opt for Reimbursement Claim Settlement. The Reimbursement Claim Settlement is listed below:

  1. Inform the Insurance Company about admission to the hospital. The Company will provide the Policyholder with a Claim Intimation Number
  2. Make the payment to the hospital for the medical expenses incurred and keep original copies of all the Invoices, diagnostic reports, prescriptions, and other relevant documents.
  3. Submit the relevant documents to Insurance Company
  4. The Insurance Company will verify the Claim Details, ask for additional documents if required and will approve or reject the Claim.
  5. The approved Claim Amount gets credited directly to the Bank Account of the Insured


Understanding the difference between IPD Treatments and OPD Treatments helps us make an informed choice about choosing the right Health Insurance Policy. If you still have further questions about IPD and OPD Coverage in Insurance, please reach out to us via email at insurance@qian.co.in or call us on 022-35134695. We would be glad to assist you.