Remember when you kept thinking, “Why should I avail of a health insurance policy when I can only use it as a financial security net in case of HOSPITALISATION?”

Well, guess what?

Thanks to health insurance policies with OPD (Outpatient Department) benefits, hospitalisation is no longer MANDATORY! While there are still a few conditions to avail of the OPD coverage perk in health insurance plans, you can still get substantial funding to cover your non-hospitalisation medical expenses.

Here’re a few details on OPD coverage that will help you tap the complete benefits of the feature!

What is Outpatient consultation in health insurance?

With the standard health insurance policies, a minimum of 24 hours of hospitalisation is mandatory (except for the daycare treatment and domiciliary coverage features). Thus, when it comes to Outpatient Department or OPD treatments, individuals are effectively left financially vulnerable as they have to fall back on their savings for funding despite having a plan from the best health insurance providers in India.

However, with an OPD health insurance plan, policyholders can go ahead for outpatient treatments sans any financial worries. Their cost of treatment will be covered up to the pre-decided percentage of the sum insured (or the fixed coverage assigned for OPD).

Features of Outpatient consultation (OPD) coverage in health insurance plans

Benefits of Outpatient consultation coverage in health insurance plans

  • Outpatient consultation is the primary and mandatory step for all individuals considering it offers medical insight regarding the presentation of the primary symptoms. This mandatory step is financially covered via health insurance with OPD coverage.
  • OPD is instrumental in the early diagnosis of any ailment. However, since it often exerts financial pressure on individuals, they are reluctant to take up this medical channel. With financial aid in the form of one of the best health insurance plans that offer OPD coverage, the timely diagnosis of ailments and the best-possible treatment method can be easily achievable.
  • OPD coverage in health insurance plans ensures that policyholders have easy access to medical specialists who tend to have higher fees than standard doctors.
  • In most health insurance plans that offer OPD coverage, the assigned sum insured is extensive and adequate to offer maximum financial support for outpatient treatments.
  • Health insurance which covers OPD offers financial aid to policyholders for minor ailments, unlike the standard health insurance plans in which the sum insured is available only in the cases of severe ailments that require hospitalisation.
  • The OPD coverage also extends to the reimbursement of pharmacy charges which can be a major financial relief for policyholders.

Who should avail of health insurance plans with OPD coverage?

  • Health insurance OPD coverage is ideal for those with pre-existing conditions, considering the frequent doctor consultation visit that mostly doesn’t require hospitalisation.
  • Individuals with chronic ailments like Asthma, Diabetes, Thyroid, etc., also benefit from health insurance that covers OPD. For those outpatient physician consultations, the medicines required, etc., they are now financially covered, which helps them have convenient access to premium healthcare services sans worries about its financial impact.
  • Individuals who are immunocompromised or have nominal ailments like fever or common cold also can benefit from the OPD coverage perk, considering that they do not always require hospitalisation.

Inclusions & Exclusions of health insurance with OPD

Regarding the inclusions and exclusions across OPD coverage in health insurance, there is a variation depending on the health insurance provider and the health insurance policy availed. However, the general list of inclusions comprises - doctor consultation fees, diagnostic test charges, pharmacy expenses, and investigative test charges.

Among its list of exclusions is - dental & cosmetic consultations

Best health insurance plans with Outpatient consultation (OPD) coverage

Best Plan With OPD Coverage Assigned OPD Coverage Amount
Care - Care Plus <INR 350/consultation
The sum insured is INR 5-7 lakhs: Maximum INR 1500
The sum insured is INR 10-25 lakhs: Maximum INR 2500
Care - Care Add On is available, whose maximum sum insured can range between INR 500 and 50k.
Care - Care Freedom Plan The privileges can be relied on only twice a year and are available in the reimbursement mode.
Niva Bupa Health Premia Platinum Limit INR 50k.

Should you buy a health insurance policy with Outpatient consultation coverage?

Health insurance with OPD coverage sounds too good to be true. And for a change, this is the truth. The feature has 2 major drawbacks -

  1. For most health insurance plans, the OPD coverage feature comes with a nominal sub-limit.
  2. They are never a pocket-friendly feature. If a health insurance plan provides this feature as a robust option, the chances are high that the premium has been spiked accordingly. Only in this case is it feasible that the sub-limit on these features is adequate.

Thus, the best health insurance plans for 2023 (that have been listed below) do not include the OPD feature and are yet the most popular among potential policyholders -

The best way ahead for potential policyholders would be to purchase a policy based on no copayment requirement, guaranteed restoration feature, no room rent restrictions, no disease-wise sub-limits, minimum waiting period, high No-Claim Bonus, and not based on which plan offers OPD coverage. Out-Of-Pocket methods best cover the latter since this would be more pocket-friendly than the spiked premium that policyholders would pay for the coverage.

Frequently Asked Questions

What expenses are covered under OPD cover in Health Insurance?

Under OPD coverage in health insurance, funding is offered for doctor consultation fees, diagnostic test charges, pharmacy expenses, and investigative test charges. However, this list of inclusions is subject to change based on health insurance providers and policies.

Are there any limits to OPD coverage in Health Insurance?

Yes, there is a limit to OPD coverage in health insurance plans. This sub-limit can range from INR 1500 to INR 5000, based on the insurer and the sum insured availed.

How does the OPD cover affect the premium amount?

OPD coverage feature in health insurance plans affects the premium paid by the policyholders significantly. Since insurers are financially tied towards making payments for outpatient treatments, they spike the premium considerably up to a threshold amount (determined by the chosen sum insured).

Can I avail of OPD cover benefits for pre-existing conditions?

Yes, you can avail of OPD cover benefits for pre-existing conditions.

What happens if I don't use the entire OPD cover in a year?

It depends on your product and it is still an evolving product category. But some of the Insurance companies have created product which allows you to roll over the unused cover to next year. In majority of products, the benefits will have to be used in the same year only.

How can I claim the OPD coverage benefits under my health insurance policy?

Some Insurance companies have already enabled the cashless claim features via direct orders & consultations booked through partner/ companies' apps. But most products still work on the reimbursement of claims model which will surely change in future.