Insurance Query: Coverage for outpatient department expenses

We are a family of four. I live with my wife and two children aged 7 and 12, in Pune. My children tend to fall sick often during winter. Are there any insurance offerings that cover outpatient expenses, such as doctor consultation fees? What will be the right way to approach such a situation?

Raghava

Winter is the season that we all look forward to, away from the scorching heat. But, with it comes the risk of flu or other health concerns as the infections may spread more easily in lower temperatures. I am sure you must be well-secured with a comprehensive health insurance policy.

A health insurance policy covers expenses such as in-patient hospitalisation, pre and post-hospitalisation, road ambulance cover, and day-care procedures, among others. These policies are designed to provide a financial safety net in case of a medical emergency. However, I completely understand your concerns regarding outpatient department expenses. Most health insurance policies do not cover outpatient department (OPD) costs, such as doctor consultation fees and diagnostic tests that may be frequently required if we fall ill during the winter.

However, the insurance industry is moving towards a customer-centric approach to cater to the evolving landscape of health insurance needs. There are riders/add-ons that can be bought in conjunction with a base health insurance policy, which will help provide holistic coverage.

Wellness benefits

Nowadays, many insurance companies provide coverage for OPD expenses that are directly embedded in the base health insurance policies. Here, the base health insurance policy will cover various expenses surrounding hospitalisation, and the rider/add-on or embedded plan will cover various OPD expenses and may additionally offer wellness benefits too.

These riders/add-ons, or the already embedded OPD expenses cover, provide multiple coverages such as teleconsultation cover, where the customer can opt for unlimited consultations with doctors online; doctor consultation cover, where the customer can opt to consult a doctor in person from the prescribed network centres or outside the network of the service provider up to limits specified; investigations cover for pathology or radiology expenses when prescribed; and annual preventive health check-up cover where the customer can avail free preventive health check-up during the policy period.

Additionally, some insurers provide other wellness benefits such as dental wellness, diet and nutrition consultation, emotional wellness, and physical fitness coverage. Consultation with the dentist, dental fillings, and other dental procedures such as root canal treatment and extraction are covered in dental wellness. Diet and nutrition consultations may provide expert advice on balancing good nutrition and diet and video/audio/chat consultations with renowned dieticians and nutritionists. You can consult an emotional health coach/psychologist under the emotional wellness cover. And you can avail of fitness facilities in network gymnasiums under the physical fitness coverage.

Focus on specifics

While purchasing a health insurance policy, always take a comprehensive look at your family’s healthcare requirements, considering the frequent illnesses your children may face during the winter. These wellness riders will help cover the additional out-of-pocket outpatient costs such as doctor consultation fees and other expenses.

Do compare policies, focusing on policy specifics such as waiting periods, coverage limits, and the claim process to ensure that that chosen rider/add-on or embedded plan aligns with your family’s healthcare needs. Once you have decided on the insurer and the policy, thoroughly understand its coverages, claim procedures, and renewal terms before purchasing. Always remember that there will be limits and exclusions these riders/ add-ons or embedded plans will be subjected to that will vary from insurer to insurer.

These riders/add-ons or embedded plans complement and enhance the existing health insurance policies, emphasising preventive health measures over curative ones. Your family’s health is of utmost importance; therefore, selecting the right health insurance policy with essential coverages and additional rider/add-on or embedded features will provide a financial safety net in times of need.

The writer is MD & CEO, Bajaj Allianz General Insurance

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