OPD Coverage in Health Insurance – Definition, Coverage, Exclusions, Best Plans, Claims, Benefits, Premiums | Free Quote Online

What is OPD Cover in a Health Insurance Plan? – Definition

OPD cover in a Health Insurance Policy pays for outpatient treatment costs, covering medical expenses which do not require hospitalisation. Most Health Insurance Plans in India do not provide OPD coverage and pay for medical expenses arising only out of hospitalisation. This leaves substantial OPD medical expenses out of insurance coverage since OPD Treatment does not require hospitalisation. An OPD Health Insurance Plan plugs this gap by providing coverage for OPD Treatments such as consultations, minor surgical and diagnostic procedures and follow-ups. An OPD Coverage is available as a standalone policy or as a rider to an existing Health Insurance Policy.

What is OPD Treatment?

OPD Treatment or Outpatient Treatment is defined as treatment where the Insured visits a clinic/hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient. The Outpatient Department (OPD) provides consultations, minor surgical and diagnostic procedures, follow-ups, and treatments that do not necessitate hospital admission under OPD Treatments.

What are the coverages under an OPD Health Insurance Policy?

A OPD Health Insurance Plan typically provides coverage for the following:

1. Professional Fees: Professional Fees include fees for medically necessary consultation and examination by medical practitioners to assess your health for any illness.
2. Diagnostic Tests: Medically necessary out-patient diagnostic procedures such as x-rays, pathology, brain and body scans (MRI, CT scans) etc. used to make a diagnosis for treatment from a diagnostic centre.
3. Pharmacy Bills: Drugs and medicines prescribed by a Medical Practitioner

What is not covered under OPD Health Insurance Plans?

The exclusions of OPD cover in Health Insurance Policies are listed below:

1. Facilities or services for rejuvenation or pleasure
2. Treatments for beautification, purification, detoxification etc.
3. OPD treatment outside India
4. Vaccinations, except in cases of post-bite treatment like a dog bite
5. Sterility, infertility, and related conditions
6. Complications from pregnancy, miscarriage, etc.
7. Dentures, dental treatment, and surgeries of any kind

It is important that the Policyholder understands the Policy exclusions thoroughly by reading the Policy Wordings in detail.

How to choose the best OPD Health Insurance Plan?

If you wish to purchase a Health Insurance Plan with OPD Coverage, it is important to compare the below mentioned coverages:

1. Waiting Periods: Many Health Insurance Plans offer OPD Coverage only after a Waiting Period of 2-3 years. It is important to compare the Waiting Periods before the Health Insurance Plan begins to cover OPD Expenses under the Insurance Policy.
2. Sub-Limits: Health Insurance Plans with OPD coverage have Sub-Limits for the benefit. Most Health Insurance Plans cover OPD Expenses only up to a limit of Rs5,000 to Rs25,000. Therefore, it is extremely important to compare the Sub-limits for OPD Coverage.
3. Premiums: The last factor to compare OPD Health Insurance Plans is to compare premiums. The Premiums of Health Insurance Plans with OPD Coverage will be substantially higher than premiums of plans without OPD coverage. Policyholder should carefully evaluate the benefits of availing Insurance Coverage for OPD Expenses while paying higher premiums for the same.

List of best OPD Health Insurance Plans in India

1. Manipal Cigna ProHealth Prime Advantage Plan: Manipal Cigna ProHealth Prime Advantage Plan offers OPD Coverage. The Policyholder has an option to choose a limit of Rs20,000, Rs30,000 and Rs50,000 as Outpatient Sum Insured. The Policy has a Sub-Limit of 20% of Outpatient Sum Insured for Pharmacy Expenses. OPD Coverage is available only on cashless basis from the Network providers of Manipal Cigna Health Insurance Company.
2. Niva Bupa Aspire Titanium Plus Plan: Niva Bupa Aspire is a comprehensive Medical Insurance Policy offering OPD Coverage with a Sub-Limit of Rs10,000 for Physical Consultations and Diagnostics and a Rs2,500 Sub-Limit for Pharmacy Expenses. The Claims for Consultations, Diagnostics and Pharmacy Expenses are subject to 20% Co-Payment for Reimbursement Claims.
3. Royal Sundaram Lifeline Elite Plan: Royal Sundaram Lifeline Elite is a comprehensive Health Insurance Plan offering an OPD Coverage Sub-Limit of Rs10,000. The Policy also covers Charges for Dental Treatment, Cost of Spectacles, Contact Lenses and Hearing Aids once in 2 years with a sublimit of 30% of OPD Treatment sublimit
4. Star Out Patient Care Insurance Policy - Platinum Plan: Star Health Out Patient Care Insurance Plan is a standalone OPD Health Insurance Plan with four Sum Insured Options – Rs25,000, Rs50,000, Rs75,000 and Rs1 lakh. The Policy provides coverage for Diagnostic Tests, Pharmacy Bills, Physiotherapy, Non-Allopathic Treatments, Dental treatment and other therapeutic procedures. The Platinum Plan has a Waiting Period of 12 months for Pre-Existing Diseases.
5. Tata AIG Medicare Premier: Tata AIG Medicare Premier Plan is a comprehensive Health Insurance Plan offering an OPD Coverage Sub-Limit of Rs5,000 lakhs to Rs20,000 and Dental Treatment Sub-Limit of Rs10,000 to Rs25,000 depending on Policy Sum Insured. The Policy has a Waiting Period of 24 months for providing OPD Coverage.

Best OPD Health Insurance Plans in India

What are the benefits of OPD Health Insurance Plans?

Health Insurance Plans with Outpatient Department (OPD) Cover are beneficial in several ways:

1. Coverage for regular medical expenses: Today, regular medical expenses for Consultations, Diagnostic Tests are substantial and having an OPD Insurance Policy takes care of the same.
2. Tax Benefits: The Premiums paid towards OPD Health Insurance Plans are eligible for tax deduction under Section 80D Deductions under the Income Tax Act, 1961.
3. Beneficial for people with Chronic Ailments: OPD Health Insurance is beneficial for people with chronic conditions like asthma, diabetes, arthritis, and thyroid disorders who require regular doctor visits.

Daycare Treatment vs OPD Treatment – What’s the difference?

Daycare Treatment

A Daycare Treatment refers to a treatment/surgical procedure which is:

• undertaken under General or Local Anesthesia in a hospital/day care centre in less than 24 hrs because of technological advancement,
• which would have otherwise required hospitalization of more than 24 hours. Health insurance typically require a minimum 24-hour hospital stay to make a Claim under the Policy. However, technological advances now allow certain treatments to be completed in a single day, like cataract surgery where the patient can go home the same day. So, Health Insurance Policies provide coverage for such procedures under Daycare Treatments even if hospitalisation stay is less than 24 hours.

OPD Treatment

OPD Treatments or Outpatient Treatments refers to treatment where the Insured visits a clinic/hospital for diagnosis and treatment based on the advice of a Medical Practitioner. The Insured is not admitted as a day care or in-patient.

A Daycare Treatment is for a confirmed illness/ailment while an OPD Treatment can be for diagnostic or investigative purposes as well. Daycare and OPD treatments may seem similar because they both involve short durations, but hospitalization is the key difference. Daycare treatments require hospitalisation even thogh for a small duration, allowing the Insured to claim medical expenses under a regular Health Insurance Policy. OPD treatments, on the other hand, do not require hospitalization.

Are There Any Limits to OPD Coverage in Health Insurance?

Yes, there are sub-limits to OPD coverage in Health Insurance Plans. This sub-limit can range from INR 1500 to Rs1 lakh, depending on the Insurer and the Sum Insured. When you buy OPD cover, it’s important to choose the Health Insurance Plan that meets your needs.

Get Best Quotes for OPD Health Insurance Policy with Qian!

The cost of medical care is rising quickly in India, making health insurance a necessity. OPD visits are now very common. Many people visit doctors for conditions like fever, blood sugar tests, ECGs, X-Rays, and consultations with family physicians or specialists. Dental treatments, diagnostic tests, periodic doctor consultations, preventive check-ups, and medicines can cost anywhere from a thousand to 1 lakh. A Health Insurance Policy with OPD Coverage can be of immense help in such a case. Qian is a licensed Insurance Broker for Health Insurance Policies. Our team will provide you with quotes for multiple OPD Insurance Plans as well as assist you with the complete claims process. If you wish to learn more, you can reach out to us at insurance@qian.co.in or call us on 022-35134695. We would be glad to assist you.