OPD Cover in Health Insurance

The term OPD stands for Outpatient Department. It is a section of a healthcare facility that offers medical treatments to patients without admitting the patient to the hospital.

OPD in health insurance refers to a type of coverage that accounts for the expenses of an outpatient treatment without hospitalisation.

Let us understand this with an example. Suppose you go for a routine check-up at a hospital, and the doctor prescribes a couple of blood tests and X-rays. If your health insurance plan has OPD coverage, these medical expenses will be covered by your insurance.

However, if your health insurance does not have OPD insurance coverage, you will have to pay for these expenses out of your pocket.

Note that most health insurance plans do not offer OPD coverage with their base policies. You will need to purchase it as an add-on rider for an additional amount, which will be combined with the base policy premium.

Daycare and OPD procedures are both performed at a hospital, but both of them do not require an overnight hospital stay. However, even with a similar approach, there is a clear distinction between the two.

Daycare procedures refer to minor surgeries and similar treatments that require some time under observation, usually less than 24 hours, increasing the hospital stay period to a couple of hours.

On the other hand, with OPD procedures, a broader range of treatments and services are accounted for without the need for hospitalisation. The list includes doctor consultation fees, diagnostic test expenses, health check-ups, etc.

Following are some common outpatient care procedures that incur expensive treatment without requiring hospitalisation, and are eligible for claim under OPD cover.

Eye Procedures: Several eye procedures, including routine check-ups, glaucoma, cataracts, and laser treatment, are generally included in an OPD insurance policy.

Nose and Mouth Procedures: Common OPD procedures for nose and mouth include removal of tonsils, treatment for nose and mouth infections, etc. If you have health insurance with OPD benefits, you can easily claim the expenses related to these types of medical treatments.

Skin Procedures: Skin procedures like laser therapies and others are primarily done in OPD without needing you to stay admitted to the hospital. These procedures can also be covered in the OPD health insurance plan.

Meniscus Procedures: Meniscus tears and related injuries are very common in sportspersons and people engaged in rigorous physical activities. It is basically a C-shaped cartilage that acts like a shock absorber for our knees. If you have a tear in the meniscus, the doctor may prescribe an OPD procedure, which your OPD insurance policy can cover.

Let us now take a look at the main inclusions of health insurance with OPD coverage. Following are the areas that are covered by most health insurance plans with the OPD coverage add-on.

• Doctor consultations

• Diagnostic Tests

• Pharmacy Expenses

• Investigative Tests

• Preventive health check-ups (annual)

• Physiotherapy sessions (may vary based on insurer)

• Dental procedures (may vary based on insurer)

Other than the basic understanding of the various inclusions under an OPD cover, it is crucial to understand the various exclusions under this add-on to file for the correct health insurance claim.

Non-Prescribed Treatments - Any medical expense incurred due to personal knowledge of over-the-counter medicines or without guidance or prescription from a medical professional is not accounted for under an OPD insurance cover.

Expenses outside Medical - When visiting a hospital for an OPD treatment, other than the listed inclusions above, minor expenses like toiletries, registration charges, or any other additional expense for added comfort during the treatment are not included in an OPD cover.

Self-Inflicted Wounds and Injuries - Any medical treatment or procedure required by a policyholder due to negligence or voluntary participation in dangerous activities or substance consumption is not included in this cover.

Cosmetic Procedures - Any cosmetic procedures that are undertaken for beauty enhancements are not included in any OPD cover. This is because these procedures are not necessary for healthy living.

Pre-Existing Health Conditions - Most health insurance plans with OPD cover do not include pre-existing disease health insurance. However, it is important to note that certain pre-existing health conditions and diseases are commonly covered under basic health insurance plan coverage.

There are several advantages of having health insurance with OPD coverage. Some of them are listed below:

Better Financial Assistance: The primary advantage of having an OPD insurance policy is that it covers the cost of a wide range of OPD services including doctor consultations, diagnostic and investigative tests and other minor treatments that often do not require hospitalisation.

This not only eases the financial burden of the policyholder, but also allows them to access all kinds of medical services quickly without worrying about whether or not it will be covered by their insurance policy.

Preventative Treatment: Another advantage of having health insurance with OPD coverage is that it allows you to take preventative care in order to avoid falling prey to various serious diseases and illnesses. The best way to deal with a serious health problem is to prevent it from happening in the first place.

But as we all know, preventative treatment is quite expensive as it includes various diagnostic tests and medications. As a matter of fact, most people avoid routine check-ups due to their higher cost. This is where having a good OPD policy comes into the picture.

Savings Optimisation: As mentioned earlier, dealing with outpatient services on your own can be very expensive. This is because you need to pay for OPD expenses out of your pocket in a majority of cases. This can drain your savings quickly and may also lead you into debt.

However, this is not the case with health insurance with OPD coverage. You can get OPD services without disturbing your savings. Some reputed insurance providers even offer cashless OPD services that provide you with greater convenience and peace of mind. This, in turn, allows you to plan and manage your finances in a much better and stress-free manner.

Comprehensive Coverage: An OPD health insurance policy offers comprehensive coverage to a variety of outpatient services that do not require mandatory hospitalisation. This includes all kinds of minor treatments. By purchasing an OPD cover with your health insurance plan, you can enjoy all-round protection and coverage.

Increased Health Awareness: Last but definitely not least, health insurance with OPD encourages people to stay aware of their health. It allows them to get routine check-ups and take all sorts of preventative measures to keep themselves healthy and fit.

Health insurance with OPD benefits offers much broader coverage. Since the OPD coverage add-on makes your regular health insurance policy highly comprehensive, it is recommended for every policyholder.

However, there are some candidates who are strongly advised to purchase an OPD policy. Those are as follows:

Ageing Individuals: As we grow older, our health starts deteriorating regardless of how many efforts we make to stay fit and healthy. A sedentary lifestyle, increased work pressure, and busy schedules are the other things that add to our ageing issues.

If you are nearing your forties, then you should consider investing in a suitable health insurance plan with OPD benefits. This will allow you to keep your health and wellness in check without worrying about the healthcare cost.

Fitness Enthusiasts: Injuries are very common in sports. But if left unattended, they can lead to major physical problems that may even restrict you from performing any kind of physical activity.

If you are a bodybuilder, sportsperson, or fitness enthusiast indulging in heavy physical activities, then having an OPD insurance policy is highly beneficial for you. From routine check-ups to minor treatments and doctor visits, everything will be covered by your insurance.

Individuals with Chronic Ailments: If you are someone suffering from chronic health issues, then it is advisable to have OPD coverage for multiple reasons. To begin with, you never know when you might need outpatient care or hefty medicines.

Dealing with such types of sudden emergencies can be very difficult in the absence of an OPD insurance policy due to the higher cost of healthcare and pharmacy. With the right health insurance with OPD benefits, you can stay assured that all of these expenses will be covered.

Individuals with Weak Immunity: If you have a weak immune system, you are more likely to fall prey to a variety of health ailments and seasonal health issues such as viral flu and infections.

Although a majority of these issues do not require hospitalisation, they incur hefty treatment and medication costs. By having health insurance with OPD benefits, you can handle the OPD treatment cost easily.

Family Members Who Need Routine Visits: If you already purchased a family floater plan and your family includes senior citizens or people who need routine visits, then you must opt for an OPD health insurance cover.

Having an OPD cover with health insurance can provide you with complete financial assistance in case of future medical emergencies that may or may not require hospitalisation.

It allows you to make multiple claims for a variety of healthcare and medical services. Not only does it save you from paying expensive medical bills from your savings, but it also allows you to get effective healthcare treatment as and when needed.

So, for these reasons, you should consider investing in health insurance with OPD coverage.

OPD benefits included in a health insurance policy are not the same across every policy. Instead, they vary from one insurance company to another. So, when you purchase an OPD insurance policy, consider the following factors:

Coverage Limit: The very first thing to check before purchasing an OPD health insurance policy is the coverage limit it offers. You need to make sure that the maximum sum insured or the limit covers your expected OPD care.

It should be able to meet your routine consultations, medication costs, and other related services.

Network Facilities: The next important thing to consider when buying an OPD insurance policy is the network facilities it is equipped with. This is perhaps the most critical point that can help you decide the right policy for you.

The more network facilities your insurance provider has tie-ups with, the better and more convenient outpatient care you can get.

At Tata AIG, we have over 10,000 network facilities where you can receive high-quality healthcare services in a cashless manner. It means you can get the best possible treatment without having to pay out of your pocket. Your medical bills will be settled directly per your policy terms.

Deductibles and Premiums: When investing in a health insurance policy with OPD benefits, make sure to check the associated deductibles and premiums. While the former refers to an amount you need to pay out of your pocket before making any insurance claim, the latter refers to the cost of health insurance you pay at regular intervals.

As a general rule of thumb, the higher the deductibles, the lower the premiums. Based on this concept, you can adjust your premium as per your budget and financial situation.

Besides, it is advisable to keep your premium amount within your budget so that you can continue with the desired policy and coverage for the long term.

Inclusions and Exclusions: Just like any other insurance product, the inclusions and exclusions of an OPD add-on vary from one insurance firm to another. So, before making any final decision, it is highly recommended to learn about the inclusions and exclusions of the policy.

For this, go through the policy documents and confirm the same with your selected insurance provider. This is perhaps the most important step that should not be missed.

If you are confused as to which OPD insurance policy to choose, then a good idea is to make comparisons between multiple policies and providers and select the one that closely aligns with your requirements and budget.

Claim Settlement Process: The claim settlement procedure is the final phase of meeting the objective of an insurance policy. It does not matter how excellent coverage and sum insured an insurance provider offers, it will go in vain if their claims settlement process is unreliable.

Thus, it is important to work with a reliable provider with an efficient claims settlement process. At Tata AIG, we offer a higher claim settlement ratio that ensures that the mediclaim with OPD cover raised by you will be handled quickly and reliably.

Buying health insurance with OPD coverage online is quick and straightforward. All you need to do is follow the below steps:

• Visit our official website.

• Select the “Health” option.

• Click on the “Self” option under it, and click on “Get Plan” to buy a new plan.

• On the next page, enter the required details, such as name, date of birth, contact number, email address, and PIN code, to proceed.

• All health insurance plans with their respective inclusions and add-ons will appear on the screen. Check for the ones that offer OPD insurance. The list includes MediCare Premier and Premier with Plus health insurance plans.

• Review the policy terms and conditions, and upon satisfaction, make the premium payment to buy health insurance online from Tata AIG. Your health insurance with OPD benefits will be sent via email.

With the growing demand for medical insurance plans in India, assessing and choosing the best OPD health insurance in India can be tricky. It is essential to evaluate the various coverage options and add-ons available with different insurers to make the right decision.

At Tata AIG, along with OPD insurance coverage, we also offer a high claim settlement ratio, ensuring quick and reliable solutions. Additionally, our range of health insurance plans is curated to cater to individuals' varying needs and budget constraints. Our plans also come with ample customisation flexibility with a range of add-ons.

For maximum convenience, we also offer the availability of online processes for all health insurance-related requirements. Moreover, we extent cashless claim settlements at any hospital around India to provide maximum convenience to our policyholders. #GoCashless