Most of first-time health insurance buyers, as they search for a suitable plan, wonder if it will cover dental treatment or doctor consultations? The answer in most cases is no. A traditional health insurance policy typically covers in-patient department (IPD) expenses that require hospitalisation. And, out-patient department expenses such as doctor's consultation fees, health check-ups, pharmacy bills, dental treatment and diagnostic tests are not included in the insurance coverage - although OPD expenses are the ones quite common, while IPD expenses happen rarely.
Taking a lead, few insurers have started covering OPD expenses as an in-built feature in the main policy, while Star Health has launched a standalone OPD cover around 10 months ago. Erstwhile Apollo Munich also had a specific OPD plan 'Day 2 Day Care Plan', but the product has been discontinued.
"For OPD insurance coverage in India, you have three options - i) indemnity health insurance plans with in-built coverage for OPD expenses, ii) indemnity health insurance plan with optional coverage for OPD expenses for which an additional premium needs to be paid and iii) Standalone OPD insurance plan like Star Outpatient Care Insurance Policy, which covers expenses like Outpatient Consultations, Diagnostics, Pharmacy, vaccination and Physiotherapy as well as Annual Health Check Up," says Dhirendra Mahyavanshi, Co-Founder, Turtlemint, an InsurTech firm.
While standalone policies come with a specific sum-insured, indemnity health insurance plans (in-built or optional) have a limit up to which OPD expenses can be claimed. These are mostly proportional to the total sum insured of the plan.We give you details of OPD covers with three insurers:
Star Health and Allied Insurance
Most of existing policies in Star Health come with in-built OPD cover, but there is a specific OPD cover too - Star Outpatient Care Insurance Policy.
"This is the era of multi-disciplinary approach and super-specialisation towards major ailments. Therefore, an OPD cover should not only pay for consultation charges but also the investigation and pharmacy bills. Star Health OPD plan covers it all. It has four sum insured options of Rs 25,000, Rs 50,000, Rs 75,000 and Rs 1,00,000 with an average premium of Rs 9,000 based on the age of the customer and the plan opted," says Dr. S Prakash, Managing Director, Star Health and Allied Insurance.
The policy provides coverage for OPD expenses, non-allopathic treatment expenses such as ayurveda, yoga and naturopathy, diagnostics, physiotherapy and pharmacy expenses, dental treatment expenses to a natural tooth or teeth arising out of accidents incurred and ophthalmic treatment expenses arising out of accidental injuries.
Bajaj Allianz General Insurance
Bajaj Allianz General Insurance has two insurance policies with the OPD benefit - its flagship Healthcare Supreme (which includes inbuilt OPD Cover + Physio OPD) and Tax Gain Policy, which is a floater health policy, covering OPD and IPD expenses under a single policy.
The Healthcare Supreme policy covers specialist consultations for the illness or injury contracted during the policy period, investigations and medicines related to the same as prescribed by the specialist, dental procedures (root canal treatment, extractions) and consultations for psychiatric disorders.
"Our maximum liability for the above expenses shall be limited to the amount specified under out-patient expenses in the policy schedule," says Rashmi Nandargi, Head - Health Retail Underwriting, Bajaj Allianz General Insurance.
Note that there could be significant difference in the premium between the pure IPD policy and the one that comes with the OPD benefit too. "For a male of age 35 years and sum insured of Rs 10 lakh, the premium for Health Care Supreme (which includes inbuilt OPD Cover + Physio OPD) is Rs 15, 315 and for Health Guard Gold Plan (which is an IPD plan), it is Rs 11,000," adds Nandargi.
The tax gain policy that covers expenses related to dental procedures & treatment, crutches, dentures and cost of spectacles, among others under the OPD component, has various plans. The one with Rs 2 lakh sum insured comes at a premium of Rs 9,345 and has Rs 4,800 OPD SI for self and spouse. There applies 10 per cent co-payment for all claims from a non-network hospital. Waiver of the co-payment clause is available on payment of 10 per cent of loading on standard premium.
ICICI Lombard General Insurance
At ICICI Lombard, their flagship product has OPD treatment as an optional cover. "On payment of additional premium, customers may choose to cover expenses incurred on consultations, diagnostic tests and pharmacy expenses on an out-patient basis. The sum insured options vary from Rs 5,000 to Rs 20,000. To ensure hassle free claims experience, customers can even avail OPD treatment on cashless basis via IL TakeCare App which provides access to a wide range of doctors and providers," says Sanjay Datta, Chief - Underwriting, Reinsurance and Claims - ICICI Lombard General Insurance.
Who should go for OPD coverage?
If you are suffering from diseases that require frequent visits to doctor, an OPD cover will help you lower your recurring expenses. People with back-ache or neuro problems may need frequent therapy sessions. It makes sense for them to have an OPD cover that covers physiotherapy. Before you buy one, you must check the waiting period for the OPD coverage.
"OPD cover is essential for customers who think they might incur healthcare costs which do not require in-patient hospitalisation. Ranging from minor ailments like viral fever to chronic lifestyle conditions like diabetes all demand regular visits to the doctors and hence OPD insurance is important," says Datta.
In-built OPD cover versus a full-fledged policy
Having a standalone OPD cover is viable only once you already have a comprehensive health insurance policy. There is no substitute for IPD health insurance coverage.
"If you incur considerable expenses on an outpatient basis, you can consider adding the OPD cover to your base policy provided that the coverage is offered as a rider or an add-on. Choosing the add-on OPD cover or a health plan with OPD benefits, is more cost-effective than buying an exclusive OPD insurance policy and it also offers you the necessary coverage. Compare the premiums and scope of coverage of both the inbuilt benefit and the rider and then make your choice, but choosing OPD coverage as a rider is a better alternative," says Mahyavanshi of InsurTech.
The best way to take a call is the additional premium that you have to pay for the OPD coverage. If the additional premium is substantial and the chances of OPD expenses based on family's medical history is lesser then you may not need such OPD coverage. However, if you have family history of frequent medical consultation and find the additional premium affordable then it would make sense to add the OPD coverage.