Family Health Insurance

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How often do we need to go to the hospital? Not very often, especially so if you are in the pink of health. Despite all precautions, you may, however, end up visiting your doctor for consultation as part of a routine checkup or minor medical illnesses etc. Such consultations generally do not require hospitalisation, hence your health insurance may not cover the same. So, are OPD and consultation covered in Family Health Insurance Plans?

OPD Coverage in Health Insurance

OPD coverage stands for Out-Patient Department. So, if you need to visit a doctor, but do not need hospitalisation for your treatment, then it is OPD. Every cough and cold, or minor ailments, for which the doctor would prescribe medications, is done at the doctor’s OPD.

In India, with the high cost of medical treatment and inflation, health insurance companies have understood the sheer importance of OPD coverage. Thus, many insurance companies have started offering coverage for OPD.

Under this, policyholders can claim expenses for their treatment that do not need hospitalisation. The coverage spans consultation, diagnostics expenses on medicines and minor procedures.

You can avail of OPD coverage under your regular health plans as well if it is available. As against the other health insurance plans, the sum insured in the OPD coverage is a factor of the age and the medical condition of the applicant. Health insurance along with OPD coverage provides comprehensive coverage of health risks.

Additional Read: Why should newly married couples switch to Family Health Insurance cover?

OPD v/s Daycare treatment

OPD refers to the outpatient department in which you are provided with basic medical care with optimal attention without needing to hospitalise the patient. However, most people often get confused between daycare treatment and OPD. There is a similarity between the two but they are not the same thing.

The factors upon which the two variables are:

  1. Meaning:

    OPD coverage refers to the treatment done at the doctor’s chamber without any hospitalisation. However, daycare treatment is when you need hospitalisation but for a period of fewer than 24 hours.

    For example, if you visit the doctor for a stomach upset, for which the doctor prescribes some medication only, then it is OPD treatment. However, for a cataract operation, you need to be hospitalised at least for 2-3 hours; which is called DayCare treatment.

  2. Coverage under health insurance:

    Usually, most health insurance plans offer coverage for daycare procedures. However, most health plans do not cover OPD costs. It needs to be specifically mentioned in the policy. In India, there are quite a few health insurance plans that offer OPD coverage. So, if you are looking for coverage for regular doctor visits, you need to choose accordingly. 

  3. The extent of coverage:

    Daycare treatment usually does not have any sub-limit on the sum insured, the expense can be up to the entire sum insured limit. However, some treatments such as cataracts could have a cap as well.
    However, if OPD cover is available, there could be a capping on the total amount that you can claim, i.e. a sub-limit on the sum insured.
  4. Hospital admission:

    For OPD treatment, you do not need any in-patient hospitalisation. However, it may require only doctor consultation, treatment, and medical tests as applicable without hospitalisation.

    Daycare treatment is usually carried out in less than 24 hours of admission; hence making it viable for claims under the health insurance plan.

The necessity for OPD coverage

The need for OPD cover has become more apparent after the recent onset of the pandemic, it has grown to be a necessity. Here are some reasons why one should opt for OPD cover:

  1. Increased uncertainty:

    During Covid, many individuals did not require hospitalisation, however, continuous monitoring, doctor consultations, repeated tests were undertaken which led to individuals footing large bills. The stress levels around us have also become severe leading to increased instances of OPD treatments.

     

  2. Increasing costs:

    The OPD treatments, consultations and medical costs have risen faster than inflation. Many of us due to our sedentary lifestyle also carry a lot of autoimmune conditions and other chronic illnesses. It is essential to have coverage towards inpatient and outpatient care benefits which will provide adequate coverage for the medical costs comprehensively.

  3. Lower number and standards of a public health care system:

    The public healthcare system in India is already overwhelming. With low funding, even the most basic tests may not be available. Getting the best consultation or OPD treatment may be near to impossible. There is also no centralised healthcare system that keeps track of the medical records of individuals. Thus, you should build coverage to cater to your outpatient requirements.

Eligibility criteria for availing OPD cover benefit in Health Insurance

Since OPD coverage is granted to individuals based on their age and medical fitness, there are no specific eligibility criteria on OPD benefits. Thus, the quantum of OPD coverage benefit depends on the basic health insurance plan that you have availed. Typically, OPD benefit will be a percentage of the base sum insured amount. 

Additional Read: Does your Family Health Insurance has the following three features?

Reasons to avail OPD cover

Some of the reasons for availing of OPD cover are:

  • It is a means to comprehensively cover your health risks. It provides additional protection that is not available under the standard plans.
  • The coverage under this plan spans across a host of medical expenses including spectacles, contact lenses, dentures, crutches, hearing aids etc.
  • Sum insured for OPD benefit is a factor of age and medical fitness. Also, in the case of a family floater plan, the age and medical condition of the oldest member is considered.
  • You can claim tax benefits under section 80D for the premium paid towards obtaining OPD benefits alongside the premium that you pay towards the base health insurance plan.
  • You can do multiple claims for availing of the OPD benefit during the year, usually as a reimbursement; as long as it is well within the maximum limit for OPD coverage.
  • Many of the insurance companies encourage policyholders to carry forward a part of the OPD benefits to the next year just to avoid false claims or exhausting the limit without appropriate reason. 

Features of OPD cover within Family Health Insurance Plans

The major features of OPD coverage are:

  • It is the initial medical screening phase before the requirement for hospitalisation
  • Regular consultations and checkups promote disease prevention
  • Enables early-stage screening for increased success of subsequent treatments
  • Easy access to best in class medical treatment and consultations
  • Ideal for vaccinations, general illness preventions and regular checkups, consultations

Inclusions and exclusions for OPD coverage in a Family Health Insurance Plan:

While availing of any insurance plan it is imperative to look at the inclusions and exclusions.

Here are the inclusions of OPD coverage

  • Consultation fee
  • Medical tests: Diagnostic tests, X-rays, CT scan, MRI scan etc.,
  • Crutches, wheelchair
  • Vaccination
  • Regular check-ups
  • Hearing aid
  • Minor operative procedures
  • Dental treatment including dentures
  • Contact lenses and spectacles

The list is not exhaustive and not all plans offer coverage for all the above-mentioned aspects.

The exclusions of OPD coverage are:

  • Cosmetic procedures
  • Dietician/nutritionist fee
  • Purchase of BP monitors, diabetes checking instruments, weighing scale, thermometers etc.,
  • Expenses towards vitamins and supplements for general well being
  • Physiotherapy

Conclusion:

OPD coverage and consultation is a step closer to achieving comprehensive coverage against health risks. In this time and age with more infectious diseases and chronic illnesses, it becomes necessary to regularly visit your doctor to ensure that you stay in the pink of health. Like always, remember to compare all available insurance plans and choose the one that aligns with your need the most. You can visit SecureNow to gain a comprehensive understanding of the features of various plans before you choose the optimal one.

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