Personal Finance

Are OPD covers worth the money?

Bavadharini KS BL Research Bureau | Updated on February 24, 2020 Published on February 24, 2020

It helps to compare policy premiums with and without OPD cover to see if they are cost-effective

While insurers typically cover hospitalisation expenses extensively, they cover OPD (outpatient department) expenses only to a limited extent. This is because OPD claims are generally more frequent and not as critical.

However, there are health policies in the market that offer OPD as an in-built feature or rider, and there are also standalone OPD policies.

But what is OPD? It basically refers to procedures that do not require a stay in the hospital, and are done in the outpatient department. OPD plans cover expenses including doctor’s consultation fees, pharmacy bills, dental treatment expenses and non-allopathic treatment.

Here, we give you the lowdown on how best you can choose OPD covers.

About OPD products

OPD covers are usually offered as part of health insurance policies and provide coverage for expenses including diagnostic and preventive tests, prosthetics, physiotherapy, pharmacy expenses and dental treatments. They also cover consultation expenses including under the streams of ayurveda, yoga, naturopathy, siddha and homeopathy.

However, the scope of OPD coverage varies from insurer to insurer. Medical aids such as wheelchairs and crutches, for instance, are offered as part of OPD (in-built) cover by insurers such as Manipal Cigna (Pro Health plan). But, in the standalone OPD policy of Star Health Insurance (Star Outpatient Care), medical aids including hearing aids, walkers, crutches, wheelchairs and infusion pumps are excluded.

Keep in mind that OPD covers that come inbuilt with health insurance plans typically set limits on how much of the expenses will be covered. For instance, Max Bupa’s Go Active family floater plan offers up to 10 OPD consultations with a cap of ₹500-600 per consultation. Similarly, in the Manipal Cigna Pro Health Insurance plan, the OPD cover differs across plan variants. Under the policy’s Preferred and Premier Options, OPD cover of ₹15,000 per year is available, but under the Plus option, it is limited to ₹2,000 per year. The standalone OPD policy from Star Health Insurance offers four sum insured options — ₹25,000, ₹50,000, ₹75,000 and ₹1 lakh.

OPD covers are also offered as riders by some insurance companies; here, you will have to pay an additional premium. Aditya Birla Health’s Activ Health Plan is an example.

OPD claims are settled via both cashless and reimbursement mode. But note that cashless settlement is an option only when OPD expenses are incurred in the insurer’s network facilities. Some insurers, including Star Health, Max Bupa and Aditya Birla Health, offer cashless facilities on OPD covers.

Exclusions

OPD covers — be they standalone policies or come as riders or in-built in a health policy — come with exclusions and these, again, vary with each insurer. Generally, expenses incurred for weight control procedures such as bariatric surgery and medical treatment of obesity, all types of cosmetic treatments and expenses on vitamins and tonics, unless forming part of a treatment for injury or disease, are not covered.

Similarly, expenses on inoculation or vaccination (except for post-bite treatment and for medical treatment for therapeutic reasons) are usually not covered. Also excluded are administrative and non-medical charges including hospital registration fees, charges on medical records, housing-keeping and washing, telephone, private nurse fees and routine vaccinations not supported by prescription. Other common exclusions are any injury or disease attributed directly or indirectly to war or invasion, intentional self-injury and unconventional, unproven and untested medical treatments.

Your gain

Before you buy a health insurance policy compare the policies with and without OPD covers, in terms of premium amount, to see if they are cost-effective.

For instance, the standalone OPD cover from Star Health Insurance for a sum insured of ₹25,000 would cost you ₹11,080 a year, while a regular health insurance policy for an SI of ₹5 lakh is just ₹7,000-8,000 a year.

Now, if you opt for Manipal Cigna’s ProHealth (Plus variant), which is a policy with an in-built OPD cover of ₹2,000, the premium works out to ₹7,514 per year for a 30-year-old individual with an SI of ₹5.5 lakh.

Note that the wellness programme offered under health policies can also help you avail yourself of OPD facilities. For instance, if you opt for an Aditya Birla Health plan, you can earn health returns (reward points) through the accumulation of ‘Active Dayz’. If you burn 300 calories in a day, you earn one ‘Active Day’. You can use the health returns (accumulated) to pay for OPD expenses in addition to renewal premium. Similarly, certain plans offer bonus points towards unutilised OPD limits.

In the case of the Manipal Cigna Pro Health plan, a cumulative bonus of 5 per cent is offered on the unutilised OPD limit (irrespective of claims made), to be carried forward to the next policy year. This can be utilised for restoring the base sum insured or reduce the renewal premium.

So, policies where OPD benefits are in-built have some advantages. However, the choice of going for an OPD cover should be made depending on the amount and nature of expenses incurred by an individual towards out-patient treatment. That is, if you frequent hospitals (as outpatient) or take diagnostic tests due to your health condition, then a standalone OPD policy would make sense; otherwise, it is better to go for a policy with in-built OPD cover. And, before opting for a standalone OPD cover, watch out for exclusions.

Published on February 24, 2020
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