What is OPD Coverage in Health Insurance? Should you opt for it?

A few days ago, one of our customers reached out to us with an important question. They were curious about Outpatient Department (OPD) coverage in health insurance and wanted to understand whether adding it to their existing policy was a wise decision.

This is precisely what we’ll discuss in this article, helping you determine whether it is a good addition to your health insurance plan.

Best Health Insurance Policies with OPD Coverage in 2024

What is OPD Coverage in Health Insurance?

Most health insurance policies offer coverage only if you are admitted to a hospital. These are called in-hospitalisation expenses. Some policies also cover domiciliary treatments, where, if you cannot get admitted to a hospital, you can have your treatment done at home.

While in-hospital and at-home treatments are covered, there is a significant gap in coverage for outpatient consultation, which can add up to a substantial amount.

This is why some insurers have started offering outpatient department (OPD) coverage, either built into the policy or as an add-on.

OPD coverage in health insurance includes consultations, treatments, and procedures that do not need hospitalisation. This can include visits to the doctor for minor illnesses, diagnostic tests, and sometimes even prescription medications. OPD coverage can be a benefit if you frequently need medical consultations and treatments that don’t require you to get admitted to a hospital.

But like any other feature in your health insurance policy, OPD comes with its own set of pros and cons. Let’s explore some of them now.

Advantages & Disadvantages of OPD Coverage in Health Insurance Policies

Outpatient consultation is one of the first things you may do when you have the symptoms of an illness. This makes it an important part, especially for people who have pre-existing diseases and chronic illnesses. And for the people who don’t have any significant ailments, here are some pros and cons to consider:

A. Pros of OPD Coverage in Your Health Insurance Policy

1. No out-of-pocket expenses during consultations: With OPD coverage, you can visit doctors and receive treatments without worrying about out-of-pocket expenses. This is particularly beneficial for routine check-ups and minor treatments, ensuring you don't delay seeking medical advice due to the cost, as the insurer settles it on a cashless or reimbursement basis.
2. Additional premiums can be used as a tax deduction: The extra premium paid for OPD coverage is eligible for tax deductions under Section 80D of the Income Tax Act. This gives you additional tax relief, ensuring you make the most of the deductions.
3. Can claim insurance without getting hospitalised: OPD coverage allows you to make claims for treatments and consultations that do not require hospitalisation. This can include expenses for consultations, diagnostics, and even medications.
4. Convenience: OPD coverage often includes access to a vast network of doctors and clinics. This ensures you can access premium medical care without worrying about the financial implications.

B. Cons of OPD Coverage in Your Health Insurance Policy

1. Sub-limit: Most policies with OPD coverage come with a sub-limit. This means there is a cap on how much you can claim for outpatient treatments. There can also be a sub-limit on how much you can claim for each doctor consultation and how many times you can visit a doctor. Sometimes, insurers have a list of the specified doctors you can visit, and they cover consultations only with them. This can limit the extent of your coverage, especially if you need frequent medical consultations and have a history with, say, a family doctor.
2. Expensive: Adding OPD coverage to your health insurance policy significantly increases the premium. The premium rises in proportion to the OPD sub-limit, which, more often than not, makes it more cost-effective just to pay the consultation charge out-of-pocket. OPD coverage may not be justifiable if you do not frequently visit doctors or need outpatient treatments.
3. Exclusions: OPD coverage often excludes certain treatments, such as dental and cosmetic procedures. Health insurance policies without OPD coverage also do not cover them unless you are involved in an accident and such procedures are medically deemed necessary.
4. Reimbursement claims only: Sometimes, the process for claiming OPD expenses can be more complex and time-consuming than that for in-hospitalisation claims. This can be a deterrent for some policyholders who want to make OPD claims.

That said, should you opt for a health insurance policy that covers OPD?

Should you opt for a Health Insurance Policy with OPD Coverage?

Most individuals do not need OPD coverage. However, there is one particular instance where OPD coverage by your health insurance policy may be beneficial – If you have any pre-existing diseases (PEDs) or chronic ailments.

If you have any PEDs and require frequent doctor visits, medications, and minor treatments, outpatient consultation coverage could be beneficial. This also applies to people with chronic ailments such as diabetes, hypertension, etc.

However, there may be cases where you wish to opt for OPD coverage. For example, outpatient consultation can significantly increase your premiums. This can be beneficial if you’re seeking a higher tax deduction under Section 80(D).

So, if you are looking for a health insurance plan with OPD coverage, here are some of the top health insurance policies in 2024 that offer coverage for OPD treatments.

Best Health Insurance Policies with OPD Coverage in 2024

1. Care Supreme (With Care OPD Add-On): Care Supreme is affordable and comprehensive health insurance that you can purchase until you are 99. One unique feature of this policy is that it offers coverage to anyone without age as a barrier, provided you don’t have pre-existing conditions or benign PEDs, such as blood pressure, hypothyroidism, etc.

This policy covers OPD treatment along with the Care OPD add-on, and it does not impose copayments, room rent limits, or disease-wise sub-limits. It also offers coverage for day-care procedures, AYUSH, and domiciliary treatments.

Drawbacks: However, the policy is not without drawbacks. It has a higher-than-average complaint ratio and a lengthy four-year waiting period for pre-existing diseases.

  2. Aditya Birla Activ One VYTL: This variant of Aditya Birla's flagship policy has almost all the features you may require. Only one variant of Activ One covers OPD treatments, i.e. Activ One VYTL. However, all variants have no copayment, room rent restriction, disease-wise sub-limits and high no-claim bonuses. It covers pre-hospitalisation expenses for 90 days and post-hospitalisation expenses for 180 days, along with annual health check-ups, coverage for AYUSH treatments, and more.

Drawbacks: Aditya Birla has yet to meet industry standards regarding its overall operational efficiency. However, considering the improving numbers of the compliant volume (as seen in our comprehensive review of Aditya Birla), we are hopeful they will achieve it shortly.

  3. Niva Bupa Health Premia: Although Health Premia may not be at the top of Niva Bupa’s line-up, it does offer a good lineup of features. This policy has no co-payment, room rent restriction, or disease-wise sub-limit. Another benefit is that Health Premia has only a 2-year waiting period for pre-existing diseases.

One unique feature of Niva Bupa Health Premia is that it covers OPD consultations without an add-on. This cover of up to ₹50k can also be used for certain dental procedures, which we do not see in many policies. While this can be a benefit, there are drawbacks, too.

Drawbacks: One of the most significant drawbacks is that this policy's minimum cover amount is ₹ 1 crore. While this may seem like a benefit initially, it increases the premium significantly, making the policy less affordable for the masses. Apart from this, as an insurer, Niva Bupa can improve its operational metrics to be on par with its competitors.

Conclusion

While outpatient consultation (OPD) offers some benefits, it also comes with its own set of challenges. So, carefully choose whether you need this feature in your health insurance plan.

If you need help choosing the best health insurance policy, consider booking a call with our IRDAI-certified insurance advisors for honest, spam-free advice tailored to your needs.