OPD Cover In Health Insurance

As we have been reading so far, Health Insurance primarily covers expenses related to treatments that require hospitalisation. Of course a hospitalisation cost can result in a huge dent in your savings and hence covering it is important, but what about regular lab checkups, or doctor visits or medicines, also called OPD expenses - that are not part of a hospitalisation treatment. Most of us feel the pinch of such expenses on a day to day basis, especially senior citizens. No wonder, as per various reports OPD expenses accounts for 60% of the healthcare costs in India - how can they be covered under health insurance?

In this article, we discuss OPD expenses in detail and if and how they are covered under your Health Insurance policy.

What Are OPD Expenses?

OPD, or an Out-Patient Department, can be defined as the part of a hospital designed for the treatment of outpatients - patients who visit the hospital for diagnosis or treatments that don’t require hospitalizations.

For example, dermatological procedures for reducing scars, wrinkles, acne etc., can be considered as out-patient treatments. Or dental procedures, like a root canal. Or if you are facing minor health issues, like headache, cough and cold, you can visit the OPD department of the hospital, and get treated without getting hospitalised.

Are OPD Expenses Covered Under Health Insurance?

Generally, as mentioned earlier, health insurance policies are hospitalisation covers. They cover treatments and their expenses only when there is hospitalisation involved.

However, there are a few insurance companies, like Go Digit, HDFC Ergo, ICICI Lombard, that have started providing covers for OPD expenses in their policies.

For most insurance policies, like Care Insurance and ICICI Lombard, OPD is provided as an optional or add-on cover - where you will have to make an additional payment to avail it. This cover will be accessible to all members covered in individual and floater policies.

Benefits Of OPD Cover In Health Insurance -

  • You can get financial coverage against regular consultations, pharmacy bills, and hefty diagnostic charges
  • If you suffer from conditions like diabetes or asthma and need multiple consultations, the OPD cover can relieve you from the financial burden.
  • Some insurers, like Royal Sundaram, New India Assurance, etc. cover the cost for dental treatments under the OPD Cover.
exclusion of health insurance plans

Not Covered In Health Insurance

  1. Pre-existing Deceases for a Fixed Term
  2. Cosmetic Surgeries
  3. Injuries caused due to suicide attempts

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What Is Included Under The OPD Cover?

Medical bills could be huge, especially if you are a senior citizen who needs regular medical care.

The OPD cover will financially protect you against the expenses incurred during -

  • Consultations
  • Diagnostic tests
  • Medical drugs, and
  • Outpatient dental treatment

What Are The Components Of OPD Coverage?

Medical expenses for treatments that do not require hospitalisation are usually of the following types:

  • Free doctor consultations
  • Dental consultations
  • Free medicines
  • Preventive medical check-ups

Types Of OPD Expenses Covered -

Medical Consultations As An Out-Patient

  • As discussed earlier, expenses incurred in the out-patient department, like doctor consultations, diagnostic tests, pharmacy bills, etc. may be covered.
  • Insurers, like National insurance, Royal Sundaram, ICICI Lombard, etc., cover such expenses.

Out-Patient Dental Treatment

  • Insurance companies, like Digit insurance, HDFC Ergo, etc. provide coverage for the expenses incurred during dental treatments in OPD.
  • Not all expenses related to dental treatment will be covered by all insurers. Some may have certain conditions attached.

For example, Digit Insurance covers the dental expenses only if the treatment is necessitated due to an accident. And HDFC ergo covers only the cost of X-rays, extractions, amalgam, root canal treatments, and prescribed drugs for the same.

Insurers, like HDFC Ergo, apply a 3-years waiting period for dental expenses to be covered under the OPD cover. This means, you’ll have to wait for 3 years before you can start reaping the insurance benefits.

OPD Ophthalmic Eye Treatment

  • Insurance companies, like Star Health, cover the expenses incurred for eye treatments.
  • The coverage is given only if the treatment is done under a licensed ophthalmologist in the OPD department of a hospital.
  • Also, the treatment must be medically necessary to treat an eye problem. If so, few insurers like Star Health will even cover the cost of spectacles and contact lenses will also be covered.

Key Conditions Under The OPD Cover

Here are some key conditions in leading plans under OPD cover that you must be aware of, before you sign up.

  • Limited Usage

    OPD benefits can be availed only once or twice in a policy year as per the policy terms and conditions. This may vary across insurers.

    For instance, Care Insurance mentions in their policy documents that you can avail this benefit only twice during a policy year.

  • Waiting Periods

    Some insurers, like HDFC Ergo, New India Assurance, etc., have stated in the policy that to avail the OPD benefit, you will have to be covered under the policy for at least 2 consecutive and continuous policy years.

  • Benefits May Be Available Only At Network Hospitals

    Hospitals that have an agreement with the insurance company, and/or are mentioned in the insurer’s list are called Network Hospitals. Some insurance companies will be providing coverage for OPD treatment only if you get treated under a Network Hospital.

    For example, insurers like Star Health, Go Digit, HDFC Ergo, etc, have this condition mentioned in their policy documents.

  • Coverage Is Subject To Limits Mentioned In The Policy Document

    Most plans will have a certain separate limit for OPD expenses

    For instance, HDFC Ergo has set a limit of 50% of the sum insured, whereas policies like ICICI Lombard have set a capping of Rs. 10,000.

  • Benefits Cannot Be Carried Forward

    Like the hospitalisation cover, any unused benefit under the OPD cover for one policy year cannot be carried forward to the next policy year.

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Types Of OPD Expenses NOT covered

  • Therapy Sessions With A Psychological Counsellor

    Expenses incurred for any kind of psychological therapy session taken under a psychological counsellor is usually not covered.

  • Cosmetic Dental Treatments

    Insurance companies, like National Insurance, have mentioned in their policy document that expenses incurred towards cosmetic dental treatments - to straighten, lighten, reshape, and repair teeth - will not be covered. Cosmetic dental treatments, like - veneers, crowns, bridges, tooth-coloured fillings, implants, and tooth whitening - are also excluded.

    However, ICICI Lombard has mentioned that expenses for such treatment will be covered only if they are necessitated by an accident. In ICICI’s case too regular cosmetic treatment (non accidental is not covered)

  • The Cost Of Spectacles, Implants, Hearing Aids, Etc.

    Insurers, like Digit, have mentioned in their policy document that they will not cover any expenses incurred for buying spectacles, contact lenses, hearing aids, ambulatory devices, etc.

  • OPD Treatments Availed Outside India

    Any OPD treatment undertaken outside India will not be covered - unless it is mentioned in the policy wordings.

    For instance, Care Insurance offers an additional OPD worldwide cover as well along with the regular OPD cover. So, you can get an OPD cover for treatments worldwide along with treatments in India.

    Please note: A few of the commonly mentioned exclusions have been noted down here. There may be more, depending on the insurance company.

    The OPD is visited daily by a large section of the community, and is one of the busiest departments. So if you are a person who needs to visit the doctor on a regular basis, the OPD cover will help you take care of the expenses arising out of the check-ups and consultations. After all, a medical cover is best when it is comprehensive, when it covers every phase of healthcare.

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