OPD Cover in Health Insurance

• Written by Riya Lohia

  Reviewed by Munmi Sharma

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Health insurance plans offer various coverage options, including critical illness, maternity, and in-home care. These are typically available as add-ons to your main policy, allowing you to personalise your coverage. One such add-on is OPD (Outpatient Department) cover, which is widely offered by insurers. OPD refers to the part of the hospital for patients who don't need to stay overnight. OPD insurance covers costs like doctor visits, tests, and medications. Think about adding OPD cover to your policy for more complete protection, as it takes care of all medical costs related to outpatient services.

What is OPD cover in Health Insurance? 

OPD cover, also known as Out-Patient Department cover, is insurance that pays for medical costs for treatments that don't require a hospital stay. Unlike most health insurance, which mainly covers staying in the hospital, OPD insurance covers things like doctor visits, tests, and minor procedures done without being admitted to the hospital. Knowing about OPD coverage helps you make smart choices about your health insurance.

Why are OPDs Important?

OPD, stands for Out-Patient Department, is the department of a clinic/hospital responsible for the medical diagnosis of a patient. It may also include minor surgeries and screenings. OPD consultations help the physician to diagnose the illness and proceed with the treatment further. Post COVID, the strikingly rising number of OPD visits has made it easier for people to keep a close eye on their health. Not to forget, OPD expenses can be hefty as well depending on the types of diagnosis. Hence, Outpatient medical insurance can be a useful coverage that helps cover the OPD expenses of the insured individual. Continue reading to know more about OPD health insurance.

Benefits of OPD Cover in Health Insurance

Medical insurance with OPD benefits offers coverage against the medical expenses for doctor's consultations, diagnostic tests, and treatments needed as an outpatient. Let us discuss some of the benefits of OPD coverage in health insurance:

• Reduces out-of-pocket Expenses: With OPD coverage, expenses related to doctor consultations, diagnostic tests, and medications are covered, which can reduce your out-of-pocket expenses.
• Financial Relief: Reduces out-of-pocket expenses for routine medical care.
• Comprehensive Coverage: Provides coverage for a wide range of outpatient services.
• Encourages Preventive Care: Promotes regular health check-ups and early diagnosis.
• Flexibility: Allows policyholders to seek medical care without the need for hospitalisation.
• Tax Benefit: Premiums paid towards an OPD cover are eligible for tax benefits under the relevant sections in the Income Tax Act. You should always ensure that you are fully aware of the benefits, inclusions, and exclusions before buying any policy.

Types of OPD (Outpatient Health Insurance) Covered in Health Insurance

Here is a list of coverage mostly provided under outpatient health insurance:

• Doctor's consultation
• Diagnosis of diseases
• Minor medical treatments/procedures
• Post-hospitalisation follow-ups
• Pharmacy expenses
• Investigative tests.

What are the Inclusions in OPD Cover In Health Insurance?

OPD (Outpatient Department) coverage in health insurance includes a variety of medical expenses. Depending on the insurance company, additional covers may also be available.

• Consultations with healthcare professionals, such as doctors and specialists.
• Diagnostic tests include blood tests, X-rays, and ultrasounds.
• Prescribed medication from the doctors.
• Preventive health check-ups and screenings.
• Physiotherapy sessions and alternate therapies.
• Minor procedures are performed in an outpatient procedure, such as suturing a wound.

What are the Exclusions in OPD Cover in Health Insurance?

There are some things that are excluded from the OPD cover in health insurance. Here are some common exclusions:

• Pre-existing Medical Conditions: Any kind of expense related to pre-existing medical conditions are usually excluded from the scope of coverage up to a defined waiting period. This is to prevent insurance misuse and ensure the policy is used for new health issues arising after the policy's start date.
• Cosmetic Procedures: Cosmetic treatments, such as plastic surgery or Botox injections, are usually excluded from OPD coverage. They are considered non-essential and elective.
• Experimental or unproven Treatments: If a treatment taken is experimental or ineffective, it will be excluded from the insurance plan. Most insurers avoid covering these treatments because they lack sufficient evidence of their efficacy and safety.

How Does OPD Cover Work in Health Insurance?

OPD insurance works by paying you back for medical costs you have when you get treatment without staying in the hospital. You can ask for this money back by giving the insurance company your bills and prescriptions. Some insurance companies also let you get treatment at certain hospitals and clinics without paying upfront, which makes things easier. Knowing all about how OPD insurance works helps you get the most out of your health insurance plan that includes OPD coverage.

Who Should Buy OPD Cover in Health Insurance?

Although, anyone can buy outpatient health insurance, OPD cover may not be an in-built feature. Insurers like Care Health Insurance offers this as an add-on cover with the basic health insurance.  If you too are planning to buy one you should consider knowing these:

• People with a family history of lifestyle diseases are at a higher risk. Diabetes is one such common disease. If your parents or siblings are diagnosed with diabetes or such lifestyle diseases, it is best for you to go for regular health check-ups. For such a case, health insurance outpatient coverage can be quite beneficial. 
• For those who are looking for a comprehensive health insurance plan, having medical insurance covering outpatients can be a great choice! From in-patient hospitalisation, and daycare treatments, to out-patient, all the admissible expenses will be covered under a single plan.
• As you age, the risks of diseases and the need for robust health care increases. Regular check-ups become more important than ever before. Hence, older adults must have OPD coverage so the related admissible expenses can be covered.
• Those who have pre-existing diseases must opt for a comprehensive health plan that includes OPD coverage. Since chronic illnesses involve regular hospital visits, OPD coverage can benefit in many ways.
• When you have a financial cushion that is there to take care of your medical expenses, you can act worry-free. You no longer have to delay check-ups or compromise with a quality diagnosis and treatment.
• Outpatient medical coverage is not limited to individual health plans or to one insured member. Whether it is an individual health plan or a family floater plan, the option of purchasing OPD care coverage is generally available for everyone. Hence, all the insured members can enjoy OPD coverage.
• Health problems may not always require hospitalisation. Many people need proper diagnosis and the medicines can suffice their health needs. Outpatient health insurance can be a mental peace for you since you do not have to stress over OPD expenses.

Are Daycare and OPD the Same?

Insurance industry is full of jargons that may create confusion at times. When it comes to understanding outpatient health insurance, daycare cover is a common term that is mistakenly being used interchangeably.

Although both OPD and daycare covers do not involve in-patient hospitalisation expenses, these two are quite different. Refer to this table below to understand the differences between outpatient and daycare coverage of a health insurance plan:

Depending on the medical procedure, the costs of OPD and daycare treatments may vary. With Care Health Insurance, you get coverage for both OPD and daycare treatments as a comprehensive health insurance plan.

>> Also Read: Inpatient vs. Outpatient Care: What Your Health Insurance Covers?

End Note

Be it diagnostics, medical investigations, minor treatments, or pharmacy expenses, outpatient insurance can offer you a reimbursement for all these expenses. The continuous rise in medical costs and increasing cases of lifestyle diseases have made it important for people to invest in a comprehensive health plan. Adding OPD coverage to your health insurance can be of great significance, especially to those who are suffering from chronic diseases. You can get Care OPD as an optional cover along with your family health insurance and get coverage for 4 specialist consultations in OPD. Connect with our experts to know more about the plan and manage those unplanned yet necessary expenses.

Disclaimers: The above information is for reference purposes only: Policy Assurance and Claims at the underwriter's discretion.