Personal Finance

Do you really need an OPD cover?

Kapil Mehta | Updated on August 24, 2018 Published on August 19, 2018

You can take a call, based on the amount, nature of expenses and claims process

While hospitalisation bills can get quite scary, the expenses incurred in the out-patient department and for diagnostic tests can make a sizeable dent to your budget too. For instance an MRI can cost ₹10,000; blood tests up to ₹3,000, medication for chronic ailments such as hypertension and diabetes over ₹10,000 a year, specialist consultation ₹1,000 per visit. These costs are generally not paid for by medical insurance.

Insurers hesitate to offer OPD cover for a few reasons. First, it results in a large number of small claims that increase the insurer’s workload. Second, pharmacies and diagnostic centres are fragmented, which makes it difficult to build a reliable network.

Insurers are willing to cover selective OPD costs such as those incurred 30 days before and 60 days after hospitalisation, within the overall sum assured. OPD costs that do not result in hospitalisation are not paid. So, for example, an ultrasound that gives you a clean chit will not be paid for. Insurers have now started adding separate OPD covers to their base plans.

Some products with OPD benefits are Apollo Munich’s Health Wallet, Bajaj Allianz’s Health Care Supreme, Cigna TTK’s Pro-health Insurance, Future Generali’s Health Total Superior, ICICI Lombard’s Complete Health Insurance, Max Bupa’s Health Companion, Heartbeat & Go Active.

Selecting an OPD cover

The manner in which OPD benefits are offered varies depending on the amount, nature of expense covered and claims process. Understanding these three aspects will help you decide whether the OPD is worth paying for.

OPD plans come with maximum spending limits, which can range from a few hundred rupees to ₹10,000 or more. If a limit is not specified, but the insurer lists the number of consultations or other benefits allowed, then apply a rough value to that to see what the implicit limits are.

The question to ask is if the amount of OPD cover is material. OPD plans are priced with a small insurance element. What this means is that if you are getting ₹5,000 as an OPD benefit, then an additional premium of ₹3,000-5,000 will be charged for that.

Some OPD plans allow medical expenses to be claimed. However, more common is some form of restriction. For example, one insurer restricts the benefit to eye and dental care, another to vaccinations. Read the policy wordings on OPD carefully to know what is insured.

Processing restrictions

Finally, insurers will specify a claim process. This specification can make a difference to the usefulness of the benefit. A common restriction is on the number of times in a year that a claim can be filed.

If there is a restriction of no more than one or two claims, then you need to keep your bills carefully throughout the year and claim when allowed. Another restriction is the OPD services must be taken in pre-identified hospitals or pharmacies. In that case, make sure the options are in convenient locations.

There are two ways to check out-of-pocket OPD expenses.

First, approach general practioners before reaching out to specialised doctors, for they are less expensive. Second, understand the new OPD-oriented products that are to be launched over the next year, before you buy.

The first health insurance you should buy is mediclaim. This should be supplemented by critical illness insurance. Once these two plans are in place, you should think about your OPD needs.

The writer is Managing Director,

Published on August 19, 2018

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