Do you visit doctors frequently? Buy a health plan with OPD cover

Before you buy it, make sure the policy is not overly restrictive

While a large portion of healthcare expenses are incurred on out-patient department (OPD) treatments, most traditional health insurance plans didn’t cover the cost of these treatments. However, several health insurance policies launched in recent times offer coverage for OPD treatments. Some insurers offer this coverage as a rider. A few standalone OPD covers are also available.

OPD covers have gained in popularity after the three waves of Covid-19.

“The demand for OPD covers has risen significantly, especially after the third wave, as the pandemic had after-effects on people’s health. Such people want to consult their doctors regularly. Since such checkups don’t require hospitalisation, an OPD cover becomes vital for them,” says Naval Goel, founder and CEO, PolicyX.com.

The growing preference for telemedicine has also provided a fillip to demand. “Post Covid, more customers prefer products that cover online OPD and e-consultations,” says Amit Chhabra, head-health and travel insurance, Policybazaar.com.

Ambit of coverage

This cover reimburses OPD expenses such as doctor’s fee, cost of medicines, costs of diagnostic tests, and other treatments that don’t require hospitalisation. For example, if the insured person meets with an accident and suffers a fracture, this policy will pay the doctor’s consultation fee, cost of plastering the limb, and the cost of medicines. A standard health insurance policy won’t cover a fracture caused by an accident if the patient does not get hospitalised.

These policies also come in handy when the insured undergoes dental treatment. “Health insurance policies usually don’t cover medical costs incurred on dental treatments like fillings, root canal, tooth extraction, etc. In fact, even those policies that cover a few listed day-care treatments, don’t cover dental treatments. However, many of the recently launched health insurance plans that come with OPD covers provide protection against dental issues as well, including the cost of dentures up to a certain limit,” says Chhabra.

Key exclusions

OPD policies don’t cover the cost of cosmetic procedures, vitamins and supplements, and physiotherapy sessions. “The exclusions for OPD covers are similar to those for health insurance plans where the facilities, services or treatments availed for rejuvenation, pleasure, beauty, spectacles, lenses, implants, hearing aids, prosthetic devices and braces are not covered,” says Goel. Read the policy wordings carefully to understand the exclusions.

OPD covers also have a waiting period. “Some of the standalone OPD plans that have been launched recently come with merely 90 days or lower waiting period,” says Goel. Many of these policies also don’t have any sub-limits.

Impact on premium

No standard OPD product is available, so buyers should take into account both the benefits offered and the sum insured while comparing premiums. Premiums are on the higher side for these policies. “Since OPD charges are high and are incurred frequently, health insurance plans that include OPD coverage are relatively expensive,” says Goel.

Do a cost-benefit analysis before purchase

Premiums are for a sum insured of Rs 25 lakh for a 35-year-old

Insurer	Plan	Annual benefits (Rs)	Monthly premium (Rs)	Annual premium (Rs)
Care	Care Plus	2,500 for OPD and 2,500 for dental treatment	1434	17197
Nive Bupa	Go Activ	Up to 2,500	1045	12538
Star Health Insurance	Star Comprehensive	Up to 3,300	1502	18013
Aditya Birla	Activ Health Platinum Enhanced	Up to 1,000	1109	13301

Source: Policybazaar.com

Run these checks

Check if the policy comes with restrictions. “Is there a limit on the number of chemists from whom you can buy medicines? Is the claim process cashless or reimbursement? Cashless is preferable. In the reimbursement option, check if you can file whenever you want, or only once a year,” says Kapil Mehta, co-founder and managing director, Secure Now Insurance Broker.

Another major point you should check at the time of purchase, according to Mehta, is that if you make an OPD claim, that should not cause the no claim bonus (NCB) you have accumulated in the main policy to get affected.

Who should buy?

OPD covers are beneficial for those who have to pay frequent visits to a doctor. “It is not always advisable to include an OPD cover in your health policy as it generally comes with limits which a policyholder can pay out of his own pocket. However, in case a person has a pre-existing or chronic disease, low immunity, or is highly prone to vector-borne diseases, such a person should opt for an OPD cover,” says Goel.