What is OPD Cover in Health Insurance?

Health insurance plans are quite comprehensive in their scope of coverage. They allow coverage for your medical bills for pre-, during, and post-hospitalization. Besides, if you are hospitalised for a few hours for treatments that are medically advanced, such treatments are called day care procedures and they are also covered under the scope of your policy. But what about the illnesses or injuries that do not require hospitalisation? Do health plans extend coverage for medical costs incurred on an outpatient basis?

According to a survey conducted by ET Prime, OPD expenses account for 62% of the healthcare costs incurred by individuals. With the recent pandemic, these costs have increased considerably.

What are OPD Expenses?

Simply put, OPD or Out-patient Department expenses are those that you incur on an outpatient basis, i.e. without being hospitalised. For instance, if you suffer from a fever and you consult a doctor, the consultation fee would be an example of an OPD expense. Moreover, the medicines and the diagnostic tests prescribed would also fall under the ambit of OPD costs.

What is OPD Insurance Cover?

The expenses that you incur on an OPD basis can be claimed under the OPD insurance cover.

Many health insurance plans allow coverage for OPD expenses. For example,

Availing OPD Coverage

OPD coverage under health insurance plans is available in three different forms. These are as follows:

1. As an Inbuilt Benefit
   Many health insurance plans allow OPD insurance coverage as a part of the inbuilt coverage benefits. If you buy the policy, you automatically get covered for OPD expenses.
2. As an Optional Add-on Cover
   Under many health plans where the OPD coverage is not available as an inbuilt benefit, it is allowed as an optional cover. The cover becomes voluntary and if you want, you can add it to your policy. An additional premium would be required to add the optional add-on to the base policy for availing OPD coverage.
3. As a Standalone Plan
   Few insurers also offer standalone OPD-oriented health insurance plans that cover you for nominal medical expenses that you incur on an outpatient basis.

Important Facts about OPD Coverage
Though you can avail of OPD coverage through multiple options, here are some important facts that you should keep in mind –

1. Basic coverage is allowed for doctor’s consultations, medicines and diagnostic tests. Some plans, however, also include dental and ophthalmic expenses incurred on an outpatient basis. You should, therefore, check the scope of coverage when opting for OPD insurance
2. There is, usually, a sub-limit on the extent of coverage available for OPD expenses under most plans. Some plans, however, go a step ahead and allow coverage up to the Sum Insured too.
3. Sub-limits could be applicable on a per visit basis, and there might also be a limit on the maximum visits allowed in a year
4. In the case of optional OPD coverage, there might be a waiting period within which coverage for OPD expenses would not be available. Once the waiting period is over, you would be able to enjoy the coverage. Also remember, the waiting period would apply from the date to add the optional OPD add-on to the policy.
5. Even in the case of inbuilt OPD coverage, there might be a waiting period after which the coverage would be available.
6. Some insurers might cover OPD expenses only if incurred at a network facility or a network hospital.

OPD coverage, therefore, has its fair share of terms and conditions that you should be aware of when you are opting for it. Read the fine print of the scope of coverage and the conditions associated thereof mentioned in the Policy Wordings or Customer Information Sheet, so that you are clear on what your policy would cover and what it wouldn’t. This would help you pick the right policy and also avoid claim rejections.

SANA.Insure has tied up with leading health insurance providers of India allowing you to avail of OPD coverage with your health insurance plans. On SANA.Insure’s platform, you can find the right choice of health insurance that extends OPD coverage, either as an inbuilt benefit or as an add-on option.

You can also compare the scope of coverage across different plans and choose the right policy. In the case of doubts, you can reach out to us for personalised guidance in buying the right plan. Our Health Insurance Experts are happy to help you should you need any assistance along the way. Please get in touch with us over WhatsApp chat on 8278271818 or call us on 18002028118 for more information.

Wish you a healthy and happy life!