Check costs, sub-limits and network restrictions before buying OPD cover

Read the policy wording and understand the sub-limits and network-related issues before purchasing the policy

At Business Standard’s Banking, Financial Services and Insurance (BFSI) Insight Summit held recently in Mumbai, a panellist drew attention to a gap in health insurance: Around 67 per cent of India’s healthcare spending goes towards outpatient department (OPD) expenses, but only a single-digit share of health insurance premiums goes towards OPD cover. Buyers need to assess whether an OPD policy offers enough usable benefits to justify the additional premium before purchasing it. 

Why OPD remains underinsured 

OPD expenses tend to be small and recurring. Patients naturally focus more on obtaining hospitalisation coverage, where the bills can at times be very steep. 

The premium may be a considerable percentage of the sum insured. “Many of the available OPD covers tend to offer low insurance value, which limits the number of buyers,” says Kapil Mehta, co-founder, SecureNow. 

 

What they cover 

OPD covers typically pay for online and in-person doctor consultations, diagnostic tests, and medicines bought from pharmacies. 

This coverage is mostly available as a rider. “The scope of coverage varies by insurer and product,” says Minoo Mantri, executive vice president (EVP), insurance, Anand Rathi Share and Stock Brokers. 

Limits and exclusions 

Some OPD policies offer a limited sum insured. Others impose sub-limits on consultations, diagnostics and medicines. Some may cap the payout allowed for each consultation or restrict the number of consultations in a year. 

“Comprehensive OPD plans without sub-limits are now available, but their pricing is on the higher side,” says Rohan Goel, business head of health insurance, Policybazaar. 

The provider network is another constraint. Policies may restrict usage to specified hospitals, doctors, clinics or pharmacies. Customers may not have a good claim experience if they get treated by a doctor outside the network. Treatment outside the network at times requires a co-payment. 

Some policies offer reimbursement only. Many come with waiting periods for pre-existing diseases and minimum claim thresholds. 

Pharmacy benefits often cover prescribed medicines only. “Over-the-counter medicines and supplements are common exclusions,” says Arun Ramamurthy, co-founder, Staywell.Health. Diagnostic benefits may similarly cover only tests recommended by a registered medical practitioner. 

Variants with and without dental and vision benefits are both available. The latter have a significantly higher premium.

Preventive health check-ups, physiotherapy and vaccinations may have separate limits or eligibility conditions. “Some policies may exclude certain wellness-related services,” says Mantri. Some may not cover cosmetic or non-medical expenses, including plastic surgery and alternative therapies. 

“The claim procedure these policies have can make them difficult to use,” says Mehta. 

Who should consider it 

People with chronic or ongoing health conditions may benefit, particularly if they need frequent doctor or specialist consultations, diagnostic monitoring, prescribed tests or medicines. 

“Families with young children and senior citizens may find an OPD cover useful,” says Shilpa Arora, co-founder and chief operating officer (COO), Insurance Samadhan. 

By contrast, people who rarely visit doctors or have low annual outpatient expenses may find a separate OPD cover uneconomical. “Paying out of pocket may be cheaper, particularly if the premium is disproportionately high relative to the benefits,” says Ramamurthy. Mantri adds that people with substantial employer-sponsored OPD benefits may also get limited additional value from a separate cover. 

Choose a suitable sum insured 

Choose the sum insured based on expected eligible family outpatient expenses. “Review the previous 12 months of medical bills, including consultations, prescribed medicines, diagnostic tests and follow-up visits,” says Arora. 

Families with children and elderly members should consider a higher sum insured. 

The sum insured across modern OPD plans ranges from ₹5,000 to ₹1 lakh. “The premium generally ranges from 30 to 40 per cent of the sum insured,” says Goel. 

Run these checks 

Examine the annual limit and individual sub-limits on consultations, diagnostics and medicines. “A higher sum insured is not necessarily better if the sub-limits are restrictive,” says Ramamurthy. Also check the policy for co-payments, waiting periods and exclusions. 

Assess network restrictions and eligible providers. “See whether clinics and pharmacies in your vicinity are covered,” says Goel.

Find out whether the policy offers cashless or reimbursement facilities, or both. Review claim procedures and documentation requirements. 

“Compare the additional annual premium against the amount you can realistically claim, rather than the headline limit,” says Ramamurthy. Assess whether paying routine expenses out of pocket would be more economical. Going for this policy may only be desirable if your OPD expenses are predictable. 

Read the customer information sheet (CIS) and the complete policy wording before deciding. “The cover’s structure should match healthcare needs and offer reasonable value after accounting for the premium and applicable limits,” says Arora.

 

Tips for avoiding claim rejection 

•    Verify coverage, eligibility and remaining benefit limits before treatment

•    Use eligible network providers where required

•    Retain itemised bills, receipts, prescriptions and diagnostic reports

•    Submit complete claims within prescribed timelines

•    Avoid duplicate claims and split, altered or misrepresented bills