Health Insurance Plans With OPD Cover

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OPD (Outpatient Department) cover in health insurance refers to the coverage for outpatient treatment. It ensures that the health insurance provider covers the medical expenses of the insured incurred without hospitalisation.

This includes routine doctor visits, for which the insured can claim the expenses up to the limit specified in the policy documents. It covers the policyholder for medical consultations with general physicians, dentists, paediatricians, specialists, orthopaedics, etc. as per the need of the policyholder.

Most health insurance plans do not offer an OPD cover and hence, it is usually available as an add-on cover. Some health insurance companies in India provide OPD insurance cover along with the basic plan.

Please note that the specifics of what is covered under OPD can vary between different insurance providers and plans, so it’s always a good idea to check the details of the policy.

What is OPD?

OPD stands for Out-Patient Department. It is a term used in the healthcare industry to describe a department or section of a hospital where patients receive medical treatment or consultation without being admitted to the hospital as an inpatient.

In other words, it’s the section of a hospital where patients that require medical attention are treated. People need to pay consultation charges, and the doctor will visit the patient to conduct the necessary check-up.

It’s the first intermediary between a patient and the hospital staff. A patient if first taken to the OPD for inspection, then the doctors from the OPD refers them to the respective departments of treatment the patient needs. It is the first contact point for the patients.

What is OPD Cover in Health Insurance?

The OPD cover in health insurance refers to the coverage of the expenses related to outpatient treatment. It makes sure that the health insurance provider covers the medical expenses you incur even without hospitalisation.

Most insurance plans do not provide an OPD cover health insurance, and these are usually available as an add-on cover. Some top health insurance companies provide OPD health insurance cover along with their basic plan.

Similar to other covers available for health plans, OPD cover in health insurance plans are designed to provide you with financial assistance for health-related issues. With medical inflation consistently on the rise, even a simple and brief doctor consultation could leave your pockets significantly lighter.

So, it is important to check if the policy you choose has OPD cover. This cover includes consultation with doctors, dental treatments, diagnostic tests, treatment for fractures, pharmacy expenses and more.

Top Health Insurance Plans with OPD Cover

Policy name	Benefits	Premium costs
Bajaj Allianz Tax Gain	Minimum and maximum entry age of 18-75 years All OPD expenses covered in a single plan Claim settlement ratio of 98.61%	Starting at ₹2194
Aditya Birla Activ Health Enhanced Platinum Plan	Maximum coverage from ₹2 Lakhs to ₹2 Crores OPD limit of ₹5000- ₹20,000 Minimum entry age of 5 years in case of an individual plan Claim settlement ratio of 99.36%	Starting at ₹3887
Care Family Health Insurance Plan	Maximum coverage from ₹3-₹6 Lakhs Minimum entry age of 91 days OPD cover in health insurance from ₹5,000-₹50,000 Claim settlement ratio of 100%	Starting at ₹5277

Disclaimer: The premium costs are subject to change as per the issuer.

How Can You Buy Health Insurance With An OPD Cover?

It is easy to assess, compare, and select a health insurance policy with OPD cover by following the steps mentioned below.

Click on the ‘Check Plans’ button mentioned on the top of the page.
Enter all the necessary information in the application form
Select a health insurance policy that includes an OPD cover
Add the health insurance add-on covers you wish to include in the policy
Get a quote for the policy
Check the policy terms and the quote for the premium
Pay the premium online to complete your purchase
Await email confirmation

Features And Benefits of OPD Cover in Health Insurance Plans

Features:

Coverage: Typically covers expenses like doctor consultations (general physicians and specialists), diagnostic tests (blood tests, X-rays, ultrasounds), prescribed medications, preventive check-ups, minor procedures (wound suturing, foreign object removal), physiotherapy, and sometimes alternative therapies.

Sum Insured: Each plan offers a specific sum insured for OPD expenses, which is the maximum amount the insurer will reimburse. This sum may vary based on your age, chosen plan, and insurer.
Claiming process: You pay for the OPD expenses and then file a claim with the insurance company for reimbursement. They will reimburse you as per the policy terms and conditions after scrutinising your claim documents.
Renewal: OPD cover usually gets renewed annually along with your main health insurance plan.

Benefits:

Reduced financial burden: Covers regular medical expenses, preventing them from draining your savings.
Early diagnosis and treatment: Encourages seeking timely medical attention without worrying about costs, potentially leading to better health outcomes.
Pharmacy bills covered: Reimburses expenses for prescribed medications, which can be a significant cost factor.
Preventive care: Covers check-ups and screenings, helping identify and address health issues early on.
Tax benefits: Premiums paid for health insurance with OPD cover are eligible for tax deductions under specific sections of the Income Tax Act.
Chronic disease management: Helpful for people with pre-existing conditions requiring frequent consultations and medications.
Wider healthcare access: Encourages seeking specialist consultations or treatments at network hospitals without worrying about costs.

What Are The Inclusions And Exclusions Under OPD Cover in Health Insurance?

Here are the most common inclusions and exclusions under an OPD cover in a health insurance policy.

Serial number	Inclusions of an OPD Cover in Health Insurance	Exclusions of an OPD Cover in Health Insurance
1	In some cases, access to telephonic consultations with doctors	The expenses resulting from the treatment of injuries caused by engaging in any illegal activities
2	In some cases, coverage for OPD consultations referred to you by a doctor	The cost of medical treatment required due to any kind of substance abuse
3	The cost of visits to the clinic of a doctor	Coverage for daycare procedures, in-patient treatments, and treatments based on naturopathy
4	Individuals aged between 91 days and 65 years can be covered under an OPD cover in health insurance	The cost of cosmetic surgery and treatments
5	Diagnostic examinations and laboratory tests	Expenses of medical treatments caused by self-inflicted injuries

Why Should I Opt For an OPD Cover?

1. Pros:

Financial protection for frequent OPD expenses: If you anticipate needing regular doctor consultations, diagnostic tests, medications, or preventive check-ups, an OPD cover can significantly reduce your out-of-pocket expenses, saving you money in the long run.

Early diagnosis and treatment: OPD cover encourages seeking timely medical attention for minor issues without cost concerns, potentially leading to earlier diagnoses and better health outcomes.
Peace of mind: Knowing you have coverage for unexpected OPD expenses can provide valuable peace of mind and reduce stress related to healthcare costs.
Chronic disease management: If you have a pre-existing condition requiring frequent consultations or medications, OPD cover can help manage those costs effectively.
Tax benefits: In some countries, premiums paid for health insurance with OPD cover are eligible for tax deductions, offering an additional financial advantage.
Wider healthcare access: OPD cover might provide access to specialist consultations or treatments at network hospitals without upfront costs, expanding your healthcare options.

2. Cons:

Increased premium: Adding OPD cover typically increases your health insurance premium, so consider if the extra cost aligns with your expected OPD needs.
Claim settlement process: Filing claims for OPD expenses can sometimes be cumbersome, involving paperwork and potential claim rejections.
Exclusions and sub-limits: Be mindful of exclusions (services not covered) and sub-limits (maximum reimbursable amount for specific expenses) within your chosen plan.
Network limitations: Using network hospitals for OPD treatment might be mandatory for cashless claims and could limit your choice of providers.

Ultimately, the decision to opt for OPD cover depends on your individual circumstances:

Age and health: If you're young and healthy with minimal OPD needs, the cost of OPD cover might not be justified. However, as you age and the likelihood of needing OPD services increases, OPD cover can become more valuable.
Medical history: If you have pre-existing conditions requiring regular OPD care, OPD cover can significantly reduce your financial burden.
Financial situation: Carefully assess if the increased premium for OPD cover aligns with your budget and the potential financial benefits you might receive.
Healthcare needs: Consider your anticipated frequency of OPD services and weigh the potential cost savings against the premium increase.

By carefully considering these factors and comparing different OPD cover options, you can make an informed decision that best suits your individual healthcare needs and financial situation.

Who Should Buy a Health Insurance Plan With An OPD Cover?

An OPD cover in your health insurance plan might be particularly beneficial for the following individuals or groups:

1. Individuals with frequent OPD needs:

Young adults and working professionals: This group often visits doctors for common illnesses, injuries, or preventive checkups. OPD cover can help manage these regular expenses.
People with chronic conditions: Individuals with diabetes, asthma, or other conditions requiring frequent consultations and medications can significantly benefit from OPD coverage.
Senior citizens: As healthcare needs increase with age, OPD cover can provide financial security for doctor visits, tests, and medications.
Fitness enthusiasts: This group might require OPD care for sports injuries or physiotherapy, making OPD cover valuable.

2. Individuals seeking preventive care:

People prioritising preventive health: OPD cover can encourage regular checkups, screenings, and vaccinations, potentially leading to early detection and better health outcomes.
Women planning pregnancy: OPD cover can help manage prenatal checkups and consultations, reducing financial stress during pregnancy.

3. Individuals seeking wider healthcare access:

People living in areas with limited healthcare facilities: OPD cover can provide access to specialist consultations or treatments at network hospitals, expanding healthcare options.
Individuals with employer-provided insurance: If your employer's insurance lacks OPD cover, adding it personally can provide broader coverage.

4. Individuals seeking tax benefits:

In countries with tax deductions for health insurance premiums, OPD cover can offer additional financial advantages.

However, it's important to remember that OPD cover might not be suitable for everyone. Consider these factors before deciding:

Cost vs. benefit: Analyse your expected OPD needs and compare them to the premium increase for OPD cover.
Claim settlement process: Be aware of potential complexities in filing and settling OPD claims.
Exclusions and sub-limits: Understand what's not covered and any limitations on reimbursement amounts.

Ultimately, the decision to opt for OPD cover depends on your individual circumstances, healthcare needs, and financial situation. Carefully evaluate your needs and compare different plans before making a choice.

What Are The Eligibility Criteria For Health Insurance With OPD Cover?

There are no specific eligibility criteria to buy an OPD cover in health insurance. An OPD cover is a usual part of a standard health insurance policy. So, the eligibility criteria for the policy applies to all the covers contained therein.

As long as you fulfil the eligibility criteria for a particular health insurance policy, which comprises coverage for OPD treatments, you will not be required to meet any additional terms.

How Can You File A Claim Under An OPD Cover in Health Insurance?

You can avail the OPD cover benefits in your health insurance policy by filing a claim. This can either be cashless or a reimbursement claim.

Cashless Claim for an OPD cover in Health Insurance

If you wish to receive out-patient treatment at one of the network hospitals of your health insurance provider, inform your insurer within the specific time as mentioned in the policy and file a cashless health insurance claim.

You can get the form for such a claim at the hospital. By availing a cashless health insurance claim, you will not need to pay any amount for your treatment out of pocket. The bill shall be directly settled between the hospital and your health insurance provider.

Reimbursement Claim for an OPD cover in Health Insurance

If you have received OPD treatment at a non-network hospital, then you can file a reimbursement claim for the expenses. Inform your health insurer within two days from the date of receiving the treatment.

Submit the duly filled reimbursement claim form and the required supporting documents to the insurer. After the verification of your claim form and the supporting documents, the insurer shall settle the claim.

Out-patient treatments are common and carry significant expenses. If you wish to have comprehensive health insurance coverage, getting an OPD cover in health insurance is ideal. If you are looking for the right health insurance plan, browse through top budget-friendly policies on Bajaj Markets. Select an OPD cover in health insurance plan that best suits your requirements.

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What exactly is covered under OPD cover?

OPD cover typically reimburses expenses for doctor consultations (general and specialists), diagnostic tests, prescribed medications, preventive checkups, minor procedures, physiotherapy, and sometimes alternative therapies. Each plan has specific details, so check the policy wording carefully.

How much does OPD cover cost?

The premium for OPD cover varies depending on your age, chosen plan, sum insured, and insurer. It typically increases your overall health insurance premium but can save you money in the long run if you use OPD services frequently.

How do I claim OPD expenses?

You usually pay for the expenses upfront and then file a claim with the insurance company. Submit the bills, receipts, and other required documents as per the policy guidelines. Remember, claim settlement processes can vary.

What are the network limitations for OPD cover?

Using network hospitals for OPD treatment simplifies the claim process and might offer cashless claim options. However, some plans might restrict your choice of providers to network hospitals.

Are there any exclusions under OPD cover?

Yes, every policy has exclusions. Common exclusions include dental and optical treatments, cosmetic procedures, pre-existing conditions (unless covered by the plan), and specific illnesses mentioned in the policy. Be sure to understand these exclusions before choosing a plan.

What are sub-limits in OPD cover?

Some expenses might have sub-limits, meaning the insurer will only reimburse up to a certain amount for that specific expense. For example, there might be a sub-limit on consultations or specific tests.

Does OPD cover offer tax benefits?

In some countries, premiums paid for health insurance with OPD cover are eligible for tax deductions. Check the specific tax regulations in your country to confirm.

Is OPD cover mandatory?

No, OPD cover is not mandatory. It's an optional add-on to your health insurance plan. You can choose whether to include it based on your individual needs and budget.

What if I already have a health insurance plan? Can I add OPD cover later?

This depends on your insurer and the specific plan you have. Some insurers allow adding OPD cover as a rider later, while others might require you to switch to a different plan that includes OPD coverage.

How can I compare different OPD cover options?

Carefully compare the features, benefits, exclusions, sub-limits, network hospitals, and claim settlement process of different plans before making a decision. Consider factors like your age, health needs, budget, and preferred providers.