OPD Cover in Health Insurance

OPD coverage in health insurance covers expenses for your medical care that are incurred without being admitted to the hospital. This includes medical costs, such as consultations, diagnostic tests, pharmacy bills and minor treatments.

The term OPD stands for Outpatient Department. It is in contrast to in-patient treatment, which involves hospitalisation expenses such as room rent charges, surgery costs and other related in-hospital healthcare services.

For example, consider Ms. Smita, who identifies a small lump on her right breast. It has been there for over two years with no pain or movement. She decides to get it checked.

Upon visiting the doctor, she is advised to undergo an ultrasound scan. Based on the results, the doctor diagnoses it as a BI-RADS 3 case, which means it is a benign condition for her that only requires regular follow-ups every three months for now.

However, since she consults a senior surgeon at the hospital, each consultation costs ₹1200. Although she is not admitted to the hospital, she still incurs ongoing medical costs for follow-ups. With OPD insurance plans, she can easily cover these expenses and avoid the burden of financial stress.

Also Read: Difference Between OPD and IPD

• To Manage Regular Healthcare Expenses - OPD expenses are more common and occur more often for various reasons compared to in-patient treatments.

• To Make Multiple Claims with Ease - It allows you to make multiple claims for a variety of healthcare and medical services. This reduces out-of-pocket expenses and ensures you receive timely healthcare when needed.

• To Cover High Medical Costs - According to reports, over 90% of Indians living in urban areas spend more than ₹10,000 every year for offline consultations, medicines and more. OPD cover with adequate coverage can help cover these costs every policy year.

• To Avail Convenient Teleconsultations - OPD cover includes teleconsultations, allowing you to save time and consultation costs. Per an IBEF blog (2023) on the Evolution of Teleconsultation in India, the Indian telemedicine market is set to grow from USD 830 million to USD 5.5 billion in 2025.

Built-in Cover for High-End Diagnostics

Please Note: Medical expenses covered under OPD may vary based on individual health conditions, medical history and the specific terms of your policy. For complete details, please review your policy document carefully.

• Dental Procedures - Dental treatments, such as root canal treatment (single or multiple sittings), tooth extractions and fillings performed on an OPD basis are covered under health insurance with OPD cover.

• Eye Procedures - Several eye procedures, including routine check-ups, treatment for glaucoma and cataracts and laser therapies, are covered under OPD insurance plans. Charges for corrective spectacle lenses are also covered.

• Nose and Mouth Procedures - Common OPD procedures for the nose and mouth include removal of tonsils and treatment for infections. Health insurance with OPD benefits can cover expenses related to these treatments without hospitalisation.

• Skin Procedures - Skin treatments such as laser therapies are generally performed on an OPD basis. These procedures can also be covered under an OPD insurance plan.

• Meniscus Procedures - The meniscus is a C-shaped cartilage that protects your knee joint. If a tear occurs here, doctors might recommend an OPD procedure, which your OPD care health insurance can cover

• Teleconsultations - Get access to general or specialist teleconsultations with a qualified doctor for specific health concerns or preventive care.

Please Note: Coverage may be subject to the maximum limit as mentioned in the policy schedule. Kindly refer to the policy document for further details.

• Out-patient Treatment and Consultations

Fees paid for visiting a doctor, including consultations related to dental, vision and teleconsultation, are covered under OPD insurance plans.

• Diagnostic Tests

General diagnostic tests and high-end diagnostic tests, such as Brain Perfusion Imaging, CT-guided Biopsy and Liver Biopsy, are covered.

• Pharmacy Expenses

Expenses incurred towards purchasing medicines prescribed during OPD consultations are covered.

• Physiotherapy

Expenses incurred for physiotherapy sessions by qualified Physiotherapists to treat an illness or injury are covered.

• Medical Devices

Expenses incurred towards renting or purchasing medical devices, such as belts, splints, crutches and braces, are covered.

Please Note: Inclusions may vary based on individual health conditions and specific policy terms. Kindly refer to the policy document for detailed information.

• Non-Prescribed Treatments

Any medical expense incurred due to self-medication, over-the-counter medicines or treatment taken without a valid prescription from a medical professional is not covered under OPD health insurance.

• Expenses Outside Medical

Minor expenses such as toiletries, hospital registration charges, or any additional expense for added comfort during OPD consultations are not covered.

• Self-Inflicted Wounds and Injuries

Medical treatments required due to self-inflicted injuries, negligence or voluntary participation in dangerous activities or substance abuse are excluded.

• Change of Gender and Cosmetic Procedures

Change of gender treatments and cosmetic procedures undertaken for beauty enhancements are excluded.

• Treatment for Alcohol or Drug Abuse

Treatments received for alcohol, drug or substance abuse or any other addictive condition are excluded.

• Pre-Existing Health Conditions

Expenses related to the treatment for pre-existing health conditions are not covered until the applicable waiting period is completed.

Please Note: This is not an exhaustive list of exclusions. Please refer to the policy document for complete details.

Please Note: The eligibility criteria can vary and can be specific to certain policy conditions. Please refer to the policy document for complete details.

Daycare and OPD procedures are both performed at a hospital and typically do not require an overnight hospital stay. However, despite this similarity, there is a clear distinction between the two.

Senior Citizens

Senior citizens often face age-related health concerns, such as dental or eye-related issues. These conditions might require frequent consultations. Medical insurance with OPD coverage helps in managing the expenses for these regular visits.

Ageing Individuals

As we grow older, we become more susceptible to lifestyle-related illnesses like digestive issues and hormonal imbalances. If you are nearing your forties, having OPD health insurance can keep your health and wellness in check without the added stress of the healthcare cost.

Fitness Enthusiasts and Sportspersons

Physical injuries are very common for them. But if left unattended, these injuries can lead to serious health complications. If you are a sportsman, purchasing medical insurance with OPD coverage can cover the cost of doctor consultations and prescribed medications for minor injuries.

Individuals with Chronic Ailments

If you are someone suffering from chronic health issues, like asthma and arthritis, you may need frequent follow-ups and regular medications. Health insurance plans with OPD coverage help in covering such long-term healthcare requirements.

Individuals with Weak Immunity

If you have a weak immune system, you are prone to frequent illnesses like viral infections and seasonal flu. Although a majority of these issues do not require hospitalisation, they incur hefty treatment and medication costs, which can be covered under OPD insurance plans.

Family Members Who Need Routine Visits

If you buy health insurance for your family, especially if it includes children, elderly parents or anyone who needs frequent medical attention, OPD coverage becomes beneficial. It can cover the recurring healthcare expenses for every policy year.

Your Healthcare Needs

Assess your age, current health condition and family medical history to understand potential healthcare requirements. Evaluate your annual spending on routine consultations and medications. This will help you determine the right OPD coverage for your medical needs.

Coverage Limit

OPD health insurance covers expenses up to a certain limit, which depends on your sum insured. Check this limit and choose a suitable coverage amount that can help you meet your routine consultations, medication costs, and other related services.

Waiting Period

Coverage for OPD expenses becomes available after a specific waiting period. This could be based on a particular health condition or simply require you to stay insured for a certain number of years. Review your policy document to understand this point.

Inclusions and Exclusions

The inclusions and exclusions under OPD cover can vary based on individual circumstances. Review the policy conditions related to specific medical procedures to understand what is covered and not covered.

Premium

The premium for health insurance plans with OPD coverage depends on the type of policy and whether the coverage is built-in or added as an add-on. You can easily determine the premium using our Health Insurance Premium Calculator online.

• Navigate to the Purchase Option - Find the option to purchase OPD cover in health insurance at the top of this page. Alternatively, you can also visit our official TATA AIG website and follow the “Personal” tab -> “Health Insurance” section.

• Provide the Required Details - Choose “Self” or the individual for whom you are purchasing the policy and click on “Get Plan”. Enter the required details, such as name, date of birth, contact number, email address, and PIN code, to proceed.

• Compare Health Insurance Plans - You will see a recommended list of health insurance plans with their respective inclusions and add-ons. Review and compare options that offer health insurance with OPD benefits

• Choose and Pay - Review the policy terms and conditions and choose a suitable policy. Pay the applicable premium online. Once your application is processed, your health insurance with OPD cover will be sent via email.

Register - Download the TATA AIG Customer Application on your mobile, provide the required details and complete the registration process. The app is available on both Google Play and the App Store

Select the OPD Service Required - Choose from the available OPD services listed on the Home Page.

Follow the Process - Enter the necessary information and follow the guided steps to avail of the selected healthcare service

Coverage for OPD expenses is important for two reasons: it can become a recurring cost for ongoing health issues, and the expenses can add up significantly over time. You can buy health insurance with OPD coverage online in a few simple steps.

TATA AIG Health Insurance offers various Individual Health Insurance and Family Health Insurance plans with flexible coverage options tailored to your specific needs. Our hassle-free claim settlement process ensures quick and reliable support when you need it the most.

Explore TATA AIG Health Insurance plans, compare your options and protect yourself from unexpected out-of-pocket medical expenses.