Due Diligence. Should you buy an outpatient cover?

Not very long back, doctors charged ₹50-100 for consultation, but today, a consultation fee upward of ₹200-250 is not uncommon. The cost of diagnostic tests has also risen with imported lab equipment and increasing compensation of technicians.

But at the same time, health insurance policies in the market do not cover expenses on medicines, diagnostic tests or treatments done in the OPD (out patient department); they have a mandatory requirement of 24 hours hospitalisation. However, some insurers, such as ICICI Lombard, Cigna TTK, Apollo Munich and MAX Bupa, cover OPD expenses in their base mediclaim policy while some such as National Insurance offer an OPD cover as a rider for an additional premium. We look at OPD covers and see how costs weigh against benefits.

Not much elbow room There are a few key things to note about OPD covers. One, for small sum insured amounts of ₹1-2 lakh, not many insurers offer OPD benefits. And, in general, every insurer who offers an OPD cover limits the sum insured available for outpatient treatment. With Apollo Munich for instance, the outpatient cover is only for up to 1 per cent of the sum insured, with a cap at ₹5,000.

In Cigna TTK’s plan, for a sum insured between ₹4.5 lakh and ₹10 lakh, the maximum amount that will be paid toward OPD claims is ₹2,000. In Max Bupa’s Heartbeat Platinum Plan, a family floater plan where the minimum sum insured offered is ₹15 lakh, there is a cap of ₹30,000 on OPD claims.

OPD covers also have restrictions on the purpose for which the sum insured can be used.

In Apollo Munich’s policy, for instance, only dental procedures (done in the outpatient department) and the cost of spectacles, contact lenses and hearing aids are covered.

In the case of lenses or hearing aids, once you make a claim, you cannot claim again for the next three years.

Finally, most insurers who provide OPD covers pay for them only through reimbursement. There is no cashless facility generally on OPD treatments.

High costs Though insurers sell OPD covers as a big plus when they market their plans, OPD covers are expensive.

National Insurance, which gives an OPD cover as a rider, charges a premium of ₹6,000 for OPD coverage of ₹10,000 for two adults, with the eldest being 35 years old.

The cost of a ₹10 lakh health insurance plan with an in-built OPD cover (of maximum ₹5,000 a year) from Apollo Munich for the couple will be ₹18,447. But for a plain-vanilla health policy, the premium would be only ₹13,607.

The ₹5,000 additional premium in the former case is for the ₹5,000 OPD cover. This couple can get a ₹10 lakh hospitalisation policy for an even lower premium with Religare, for instance, for ₹10,660.

Way out OPD cover premiums do not justify the benefits offered, says Sudhir Sarnobat, Director, Medimanage, a large insurance broker.

“The best option to cover OPD expenses is to manage it from your own pocket. It makes sense to be better prepared than depend on a policy for the same,” he says. Besides, there are many insurers today who offer a comprehensive health insurance policy, reducing to a large extent the need for a standalone OPD cover.

HDFC ERGO’s health policy covers 144 day care procedures, domiciliary expenses (expenses on treatment taken at home) and Ayush treatments. The premium though is on the higher side (₹15,942 for two adults of 35 years of age) of the industry average. Some insurers also offer discounts on pharmacy bills. Bajaj Allianz, for instance, offers discounts on medicines purchased at select outlets. ICICI Lombard offers discounts on diagnostic tests, dental and eye care.

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