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OPD Cover in Health Insurance

It’s not always that an illness needs hospitalization. Often, consultation, diagnosis and treatment can be done expediently and conveniently without a hospital stay. In the world of healthcare, this is termed as OPD- ‘Out-Patient Department’ or Day Care Procedures, to distinguish these patients from the people occupying hospital beds, otherwise known as ‘Inpatients’.

If you are availing an OPD treatment or day care procedures, it basically means you are consulting a doctor, as well as other facilities at the hospital – such as check-ups, scanning etc, without getting admitted. Till recently, outpatient insurance coverage was not covered by insurance providers. But since the consultation fees, pharmacy bills, dental treatments, diagnostic tests etc. can end up burning a hole in the pocket, insurance companies have lately started offering better-defined OPD cover. Here’s what you should know about OPD cover in Health insurance.


What is OPD Treatment?

OPD Treatment means the one in which you visit a clinic / hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a Medical Practitioner. You do not have to be admitted as a day care or in-patient.


What is OPD Cover in Health Insurance?

OPD cover takes care of various day care procedures expenses such as medical bills, diagnostic tests, ambulance charges, health check-ups, dental treatments, etc., without having to get admitted in a hospital.


Why should you buy Health Insurance with OPD Cover?

Many of us, whether aware or not, fail to realize the importance of an OPD cover. The reasons could vary- After all how often do I visit the hospital? Am I really getting an X-ray, scan, blood test etc., ever so often to spend for an OPD insurance cover? One doesn’t realize that out-of-pocket medical expenses account for 62% of all healthcare costs in India.

Here are the highlights of day care procedures covered in your health insurance:

  • OPD cover allows you to make claims for expenses incurred, without hospitalization.
  • These plans offer significant tax benefits. For example, you can claim tax exemption on the premium paid. Any claims you make are TDS-exempt.
  • Cost of medicines, along with diagnostics or minor procedures are also covered under this policy.
  • Unlike other insurance policies that pay claims based on hospitalization, under OPD cover, the sum assured is based on the age of the insured.
  • You can claim OPD expenses without an extensive wait – usually, within 90 days of availing the policy if you are claiming for a pre-existing disease. Or even from day one if it is not related to any PED condition.
  • You can make multiple claims within the same year, till the limit is exhausted.

Rest assured, Outpatient insurance Coverage ensures that you always have access to the best of healthcare, without burning a hole in your pocket.


Who should take OPD Cover?

OPD Insurance Cover is a boon for anybody who might incur healthcare costs without hospitalization. This will help minor medications like viral fever and in cases of some chronic conditions like diabetes, back pain, arthritis or any other chronic condition that requires regular visits to the doctor, OPD Insurance is recommended cover.


What is included under OPD Cover?

  • Professional Fees: Fees for medically necessary consultation and examination by medical practitioners to assess your health for any illness.
  • Diagnostic: Medically necessary out-patient diagnostic procedures such as x-rays, pathology, brain and body scans (MRI, CT scans) etc. used to make a diagnosis for treatment from a diagnostic centre.
  • Surgical Treatment: Minor Surgical procedure such as POP, suturing, dressings for accidents and animal bite related outpatient procedures etc. carried out by a Medical Practitioner.
  • Medication Drugs and medicines prescribed by a Medical Practitioner.
  • Out-Patient Dental Treatment
  • Hearing Aids
  • Psychiatric Illness Treatment

What is not included under OPD Cover?

This cover excludes expenses incurred towards Spectacles, Contact Lenses and Physiotherapy, Cosmetic Procedures, Ambulatory Devices like Walkers, BP Monitors, Glucometers, Thermometers, Dietician Fees, Vitamins and Supplements.


How can you avail OPD Cover with Health Insurance Policy?

Health insurers usually offer it as an add-on with the base policy charging a little extra premium for it. Also, Outpatient Insurance Coverage might not include all day care procedures. So, it is always wise to see if your health insurer has this benefit as an add-on and on what procedures you can claim this benefit.


Outpatient Insurance coverage in health insurance is one of those benefits that might look unimportant but actually can save the day when you are in a difficult situation.

Explain it like I'm five

We're making insurance so simple, now even 5-year-olds can understand it.

You have taken a monthly subscription at your school canteen that allows you to take all the snacks and cool drinks you need. Unfortunately, you are told that it only covers the food that is bought and consumed within the canteen. That really does not work for you, because who really wants to waste time sitting down and eating a sandwich in the boring canteen when everybody is out playing in the school grounds – if only you could grab a fruit juice and a pack of biscuits and get back to play. That’s kind of how Outpatient coverage (or OPD cover) works.