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OPD Coverage in Group Health Insurance

  • Author :
  • TATA AIG Team
  • Published on :
  • 08/05/2024

The rising cost of medical facilities and the increasing cases of sedentary lifestyle diseases have made health insurance an inseparable part of human lives. Even employers opt for a group health insurance policy for their employees as a part of employee welfare programs.

Though individual and group health insurance policies provide financial assistance in case of medical emergencies, OPD is one area that brings added relief to the insured. If you are wondering what is an OPD cover in group health insurance, its benefits, and how to avail of it, then keep reading.

What is OPD Coverage Meaning in Group Health Insurance?

OPD full form in insurance is the same as in the regular medical terminology. OPD stands for Outpatient Department in health care facilities. It is a department which provides medical treatment and services to those patients who do not require overnight admission for treatment.

As mentioned above, employers provide employees with group insurance. However, not all policies include OPD coverage which can cause financial stress to the employee. OPD coverage typically offers coverage for medical bills incurred during treatment or consultation. Therefore, group health insurance with OPD coverage is the best option as it adequately covers the cost of treatment that one may require as an outpatient. This cover can be included as an add-on cover to the group insurance.

Now that you know what OPD in group insurance is, let us discuss its benefits.

Benefits of OPD in Group Medical Insurance Policy

All injuries and illnesses do not necessarily require admission. In such situations, OPD coverage comes to the rescue of the insured. Here are some of the benefits of mediclaim with OPD coverage.

Financial Assistance - The primary benefit of mediclaim with OPD cover is that the employees covered under this insurance can get financial assistance for OPD treatments such as health tests, doctor visits, diagnostic testing, and so on. It reduces the financial stress on the insured and enables him to undertake the necessary treatments without any concerns.

Allows Preventive Treatment - Since the OPD cover in group health insurance takes care of lab tests, diagnosis, medications, etc., employees (insured) can get the best preventive treatment to avoid falling prey to bigger diseases. Since preventive treatments are expensive, OPD covers the expense, allowing the insured to undergo various tests and routine checkups.

No Minimum Time - Unlike regular medical policies, which require a minimum of 24 hours of hospitalisation for filing a claim, OPD cover has no such requirement. Even if you are in the hospital for a couple of hours for treatment, you can file a claim if your policy has OPD cover.

Offers Comprehensive Coverage —Group health insurance with OPD coverage offers coverage for several outpatient treatments. An insured can be treated and undergo tests for the mentioned purposes, and the OPD cover will take care of the expenses as per the policy terms and conditions.

Inclusions and Exclusions of OPD Coverage

Though the benefits of an OPD cover may be lucrative, it has specific inclusions and exclusions that employers must consider while buying a group health insurance with OPD cover.

Inclusions:

Doctor Consultation: Health policies with OPD cover provide coverage for consultation charges of the doctor. Even if you visit the doctor for a primary health issue such as a fever, you can get assistance for the doctor fees that you pay for the treatment.

You also get financial assistance for doctor consultation charges related to chronic diseases such as diabetes, asthma, etc.

Medical Bills: All expenses arising in connection with medicine purchases, whether long-term or short-term, are covered under group health insurance with OPD coverage.

Diagnostic Tests: Expenses incurred for lab tests such as X-rays, ultrasounds, blood tests, MRI scans, etc., can also be claimed under the OPD cover of group health insurance. Many of these tests are essential in diagnosing diseases at an early stage, enabling their treatment.

Physiotherapy: Some OPD covers also include physiotherapy treatment as a part of its inclusions. Physiotherapy sessions may be required for various medical conditions and can be claimed under group insurance.

Exclusions:

Pre-Existing Diseases: OPD coverage typically does not include expenses incurred for pre-existing diseases that an employee may have suffered from before the group insurance.

Beauty Procedures and Treatments: If the insured undergoes beauty treatments and procedures that are not medical in nature, they will not be covered under the group health insurance OPD cover. This includes treatments such as lip fillers, plastic surgery, etc.

Experimental Treatments: Expenses incurred for non-prescribed medicines, treatments that a doctor does not prescribe, etc., are excluded from the scope of OPD cover.

Self-Inflicted Injuries: If an insured receives treatment for self-inflicted injuries arising from a suicide attempt, the cost of such treatment will not be covered under the OPD umbrella.

Conclusion

The role of OPD cover in group health insurance is pivotal, and offers added benefits to the insured. In most group policies, OPD must be taken as an add-on cover so employees can enjoy additional financial assistance.

However, one must also be aware of the inclusions and exclusions of OPD coverage so you can successfully claim your medical expenses. Lastly, it is also essential to mention that there is a set limit under OPD cover, which varies from one policy to another. Therefore, one must check the upper limit before raising any OPD claim.

Tata AIG is one of the highly trusted insurance providers, offering SME insurance to organisations with plenty of benefits. Our group health insurance policy helps organisations protect their employees and offers them financial assistance for medical treatments, big and small.

FAQS

Who can benefit from OPD coverage in group health policies?

In group health policies, all insured individuals can take advantage of the OPD coverage. They can make claims for all the expenses that are included in the policy's OPD coverage.

How to claim the OPD cover?

The process to raise a claim under OPD cover is usually the same as any regular insurance policy. However, it is advisable to check with the insurance provider for the same.

Disclaimer / TnC

Your policy is subjected to terms and conditions & inclusions and exclusions mentioned in your policy wording. Please go through the documents carefully.

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