OPD Cover in Health Insurance: Benefits and Coverage Explained By Way2Earn

Not every injury or illness needs hospitalization. Outpatient Department (OPD) visits cater to daycare treatment for a minimum of 24 hours or it does not require a patient to get admitted to the hospital for more than 24 hours. The health insurance plan with OPD cover provides the benefit of a medical consultation to the policyholder with a dentist, general physician, pediatricians, orthopedics and specialists. Moreover, the policyholder can claim up to a specific amount as mentioned in the policy document for routine doctor visits.

With the increasing medical inflation, it is advised to choose a health plan with OPD cover. Read this article to know the benefits of OPD cover in a health insurance policy.

What is OPD Cover in a Health Insurance Plan?

The OPD cover refers to health insurance coverage that pays for the outpatient treatment cost. With OPD cover the policyholder can ensure that any medical expenses incurred without hospitalization will be covered under the policy. In most health insurance plans, the OPD cover is offered as an add-on benefit.

Benefits of OPD Expense Coverage in a Health Insurance Plan

Health insurance policy with OPD cover benefits the policyholder in the following ways:

  • It is very beneficial for individuals who require a frequent visit to outpatient consultation that may include basic viral fever, eye check-up, etc.
  • The hefty pharmacy bills are reimbursed to the insured
  • It is beneficial to individuals who have pre-existing medical illnesses such as thyroid, asthma, arthritis, etc. and who need frequent medical consultation.
  • Helps to save income on tax deductions·

Note- OPD expenses can only be covered in the network hospitals or clinics.

Inclusions of a Health Insurance OPD Cover

The following are the coverage detail of outpatient cover in a medical insurance policy:

  • Diagnostic tests
  • OPD treatment
  • Doctor consultation
  • Pharmacy expenses
  • Investigative tests

Exclusions of a Health Insurance OPD Cover

Listed below are the exclusions of OPD cover in a health insurance policy:

  • Treatments for purification, beautification, panchakarma, detoxification, etc.
  • Services or facilities availed for pleasure, rejuvenation, etc.
  • OPD treatment outside India
  • Cost of lenses, hearing aids, spectacles, implants, braces, prosthetic devices, etc.
  • Infertility, sterility and other related conditions
  • Complications arising due to pregnancy or miscarriage
  • Routine examination of preventive health check-up
  • Vaccination including immunizations and vaccinations except in the case of post-animal bite treatment such as dog bite
  • Dental treatment, dentures and surgery of any kind

Claim Settlement Process of Health Insurance Policy With OPD Cover

The claim can be filed for OPD expenses following two different methods. Let’s take a look at it:

  • Reimbursement Claim- After receiving the OPD treatment, the insured needs to send the bills and relevant documents to the insurer. Once the insurer verifies all the documents the claim amount will be reimbursed to the account of the policyholder.
  • Cashless Claims- The policyholder can avail of OPD treatment at any of the network hospitals of the insurance company by requesting to initiate the cashless claim.

Why Should One Get a Health Insurance Plan with OPD Cover?

With the skyrocketing cost of healthcare and medical treatment in India, it has become important for policy buyers to choose the health insurance plan with OPD cover. According to the recent survey, the OPD expenses in India account for approximately 62% of the total medical care expenses as compared to the inpatient department expenses. Moreover, the visits to the doctor have also increased significantly. Thus, with an OPD cover health insurance plan, an individual can ensure that all their outpatient treatment costs can be taken care of.

Difference Between OPD Treatment and Daycare Treatment

Although OPD treatment and daycare treatment are the same, there is a slight difference between the two in the technical aspects. Let’s take a look at the difference between both treatments.

OPD TreatmentDaycare Treatment
It does not require hospitalizationHospitalization is required not more than 24 hrs
Claim settlement will be honored only for non-hospitalizationClaim settlement will be rejected if the hospitalization is done more than 24 hours.

Example- Treatment that does not require hospitalization like a root canal is categorized as OPD treatment whereas, any dental surgery required due to accident, which needs hospitalization less than 24 hours are classified as daycare treatment.

Difference Between In-patient Department and OPD Treatment

The following are the differences between IPD and OPD treatment.

Admitted for appropriate attention and careIncludes doctor visit or a clinic
It requires hospitalization for more than 24 hoursIt does not require hospitalization

Example- A heart surgery is considered as an IPD treatment as it requires hospitalization for more than 24 hours whereas, a root canal is considered as an OPD treatment.

Wrapping it Up!

A health insurance policy with OPD cover is beneficial for those who want to enhance the coverage of the primary plan along with the basic coverage offered by the policy. For individuals between the age group of 25- 40 years and for senior citizens having a health insurance plan with OPD cover is very beneficial as it ensures total financial security against any type of medical emergencies.

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