Decoding the OPD in health insurance policy

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Forty-six year old Akshat had been suffering from high-blood pressure  for some time now. This frequently pushed him to the out-patient department (OPD) of a hospital nearby. However, the ever-growing bills of doctor’s fees and his medicines do very little to soothe his frail BP levels. He was unaware that his health insurance policy provided coverage, though limited, for his regular OPD visits. 

He’s not alone. A 2023 survey by ICICI Lombard General Insurance, which studied over 732 respondents from major Indian cities, revealed that barely 26% Indians were aware of all the features that their health insurance policy had to offer. Forty-eight percent of those surveyed had no idea what terms like waiting period, even OPD meant. 

In India, if one or more than one family member falls critically ill, a major portion of an entire household’s expenses are directed towards their healthcare. If these exceed a certain threshold, the entire family is deemed catastrophically affected, financially. That’s because all other expenses take a backseat, and an entire family is pushed to the brink of poverty. 

And more often than not, it’s these OPD expenses that push families to the edge of catastrophe. A 2021 NITI Aayog report noted that 80-85% of all these catastrophically affected families had been pushed by OPD expenses, as opposed to just 40-45% families, who had been impacted due to IPD (In-patient department). IPD requires that a patient be admitted in hospital. 

So, while it is important to get an OPD, what does it actually cover? We decode it for you. 

Why do you need an OPD cover? 

So that those frequent visits to doctors don’t singe your pockets. In most health insurance policies, OPD coverage is kicked off post after a waiting period of 90 days. This means that you will be eligible to claim OPD-related expenses only after your policy has been in force for around 3 months.

Even then, you cannot claim the entire sum insured (SI) for your OPD expenses. Policies have a sub-limit or a ceiling under this head, which specifies how much of the total SI you can demand as OPD expenses. 

What is included/excluded in your OPD coverage? 

While this varies according to policy, most policies broadly cover for the doctor’s bill, medicine charges and diagnostic tests. However, some general exclusions which are not considered are: 

• Any form of cosmetic/plastic surgery
• Injuries due to participation in hazardous/adventure activities
• Treatment for drug/alcohol abuse, pregnancy, infertility
• Rejuvenation/Wellness/unproven methods of treatment 
• Cost of medical equipment used at home post surgery/hospitalization 
• Receiving treatment from medical practitioners/institutions not notified by insurer

Pune-based financial planner Sanjeev Dawar notes that when it comes to OPD coverage, the charges across service providers are substantially high. But, “if you or anyone in your family has a condition where the need of OPD attention is predictable and upfront, it’s a wiser choice to have a separate corpus to be used in case of need instead of paying a very high premium”.

But the reason why India lacks solid OPD coverage is due to lack of institutional players in the pre and post hospitalization process. Our first point of contact when a family member falls ill is a local or family doctor. “That makes it difficult for insurance companies to standardize the process and hence, the higher number of exclusions”. 

“Moreover, the idea of insurance in India is more inclined towards savings, and not comprehensive protection. People buy insurance that offers OPD coverage up to Rs 6,000, even though their actual expenses touch Rs 7,000-10,000”, continues Mahaveer Chopra, founder of Beshak.in

In case you are looking for some OPD-specific health insurance plans, take a look at this:

Most plans with OPD coverage reimburse for consultation fees and cost of medicines. However, there is a limit on the number of OPD visits or amount spent on such visits that the policy will cover during its tenure. Moreover, in some cases, you can avail benefits only if you avail OPD services from hospitals registered with the insurer. 

For instance, the Niva Bupa Go Active provides for only 10 OPD consultations in a single year. As for test costs, the policy offers Rs 2,500 per person per year. Other policies set a monetary cap on OPD limits, like the Digit Care plus OPD Insurance Plan, which has a minimum OPD benefit of Rs 2,500, and a maximum of Rs 50,000 during the policy tenure. 

The Bharti AXA Health Advant Edge Plan offers 0.5% of sum assured or Rs 1,00,000, whichever is lower, as its OPD benefit. In other cases, OPD coverage depends on your age and whether or not you’ve undergone medical testing before availing the policy. Very few policies cover dental, eye-care and alternative treatments like Unani, Ayurveda and more.