Now, get insurance for OPD, tests, dental treatment, even medicines

Under health insurance, an insured person is covered against the financial risks associated with hospitalisation. All health insurance policies offer coverage for hospitalisation of 24 hours or more and some cover daycare procedures, where patients can be discharged after a few hours of treatment.

Now, some insurance companies offer coverage for Out Patient Department (OPD) treatment, like doctors’ consultations, diagnostic tests, dental treatment and medicines. Since premiums for these policies are higher than regular policies, keep in mind conditions such as limits on sum insured and number of visits to the doctor. Let us see how these policies work.

Need for OPD cover
Explaining the rationale behind these policies, Sanjay Datta, chief underwriting, reinsurance & claim, actuarial, ICICI Lombard General Insurance, said, “Most commonly incurred medical expenses are not due to hospitalisation but because of OPD expenses. OPD expenses are expenses like doctor consultation, diagnostic tests, medicines prescribed by medical practitioner, etc, which will not be covered under a regular inpatient cover. It is better to opt for a plan with OPD so as to be covered in a more holistic manner.”

ICICI Lombard offers OPD cover as an inbuilt cover in some plans, namely, Health Protect Plus, Health Smart, Health Smart Plus and iHealth Plus.

In India, about 60% of healthcare is spent on OPD treatment, making such a cover even more critical. Especially for diabetics or parents with infants or young children prone to ailments that require over-the-counter medicines frequently, said Jyoti Punja, chief customer officer, Cigna TTK Health Insurance.

“The OPD benefit helps policyholders claim expenses not paid for under regular health policies and also maximise tax benefits under Section 80D, which allows tax deductions on health insurance premiums paid. It meets the needs of those who run up sizeable pharmacy bills every year,’’ she said.

Max Bupa Health Insurance offers OPD coverage in its GoActive Plan. “We offer both cashless and reimbursement claims for doctors’ consultations under this plan,’’ said Anika Agarwal, senior vice-president and head-marketing digital and direct sales, Max Bupa Health Insurance.

To avoid chances of fraud, there is a closed group of doctors both for reimbursement and cashless. Patients cannot go to just about any doctor and claim the insurance money, she said.

However, Kapil Mehta, co-founder, SecureNow Insurance Brokers does not recommend an OPD cover at this stage because the amount of insurance built is relatively low. “This means the additional premium paid for OPD is similar to the benefits provided. The trend of setting up an OPD network will allow for a smoother OPD experience and also facilitate the delivery of discounted costs to patients. These products should develop significantly over the next year or so,’’ he said.

How these plans work
The OPD plans are stipulated in different ways by insurers. The most common restriction is in amount. It varies from as low as Rs 500 to Rs 10,000. The second restriction is in the type of OPD. Some insurers will restrict it to items like vaccinations, dental or spectacles, but many leave the use open.

The third restriction is in the method of claiming. Some insist on settlement once a year, others allow multiple claims to be made. The payment is mostly reimbursement based. However, some insurers, have now set up a cashless network. They also tend to specify OPD in terms of use, for instance, six consultations a year in the network hospital.

Max Bupa, for instance, gives four to 10 OPD visits, depending on the family size. The company has tied up with online health service providers, Practo and 1Mg for customers to book appointments online. “On an average, a person needs to go to the doctor two to three times in a year, unless you are chronic patient. Through the tie-up with digital players, doctors are available on cashless basis. Here the payment is made to the doctor directly, so there is no chance of fraud. For reimbursement claims, customers can upload the bill through our app and get the money within three days,’’ said Agarwal.

For reimbursement, the company has tied up with 35,000 doctors in 40 cities. Doctors are selected on the basis of the city, specialisation and ratings from existing customers. The claim amount is capped at Rs 600.

In case of ICICI Lombard, the OPD limit options start from Rs 5,000 and go up to a maximum of Rs 20,000 per year. This limit varies as per the total sum insured and is for reimbursement only.

In Cigna TTK’s plans, OPD is a fixed amount as per the health insurance policy opted, ranging from Rs 500 to Rs 20,000. It is available for policies like ProHealth Protect, ProHealth Preferred, and ProHealth Premier and ProHealth Accumulate. There are plans offering including coverage for alternative medicines, preventive health check-up, bonus on unutilised OPD amount year on year, allowing OPD amount to be utilised towards payment of any co-pay or deductible under the policy.

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“Also, if the policy is not renewed, the OPD amount is available for OPD-related claims for a period of 12 months from the policy end date,” said Punja.