Are outpatient insurance covers useful?

Fewer policies are focussed on covering OPD consultation expense
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IRDAI’s recent circular on insurers leveraging a central health professional registry can support wider acceptance of OPD (outpatient department) covers in health insurance. In this light, we look at what constitutes OPD covers and the insurers that offer them.

In medical insurance, outpatient department or OPD consulting gets the short end of the stick. Fewer policies are focused on covering OPD consultation expense. Extending health insurance to adequately cover OPD consultation can be useful to specific policyholders whose medical care entails frequent consultation rather than inpatient admission. OPD care is a crucial step in medical care cycle and faces medical cost inflation and patient affordability issues just as inpatient care does. This can be addressed by health covers that focus on OPD consulting in addition to inpatient coverage.

Basics of an OPD cover

Under a typical OPD cover, consultation, along with the prescribed diagnostic tests/medicines, is covered with limits (ranging from ₹1,500 to ₹20,000 per year) as part of the overall health insurance cover. Day-care procedures (cataracts, orthopedic alignments, dialysis) are different from OPD covers and may be the domain of main health insurance cover anyway. Similarly, wellness and aesthetic consultations generally fall outside the purview of OPD cover.

OPD cover requirement for policyholders is not defined by age, disease, or other demographic markers, but is an individualized consideration. The requirement can be assessed based on the past out-of-pocket expenses for doctor consultations and future consultation schedule. For specific conditions, diabetes, cholesterol, kidney ailments, skin conditions, it is necessary to confirm the coverage under OPD (in policy documents) before considering the insurer.

The other condition to ponder and confirm is the waiting periods, even for pre-existing conditions. Specifically, leading insurers, including Aditya Birla and Manipal Cigna, have specified day-1 OPD coverage in their policy wordings and it may be beneficial to confirm similar conditions with any other insurer as well. Also mentioned in the wordings will be telemedical/virtual consultations, which are different from physical consultations. As expected, the premium will be for a physical compared to a telemedical consultation and the latter is much more common in policies, even those that may not be focused on an OPD cover.

Insurers generally provide an empaneled set of doctors/consultants to offer cashless reimbursement in OPD. Insurance regulator IRDAI has offered insurers to leverage the health professional registry to build a network of healthcare professionals for providing OPD. Amongst the many benefits, streamlined delivery of OPD services with cashless option can vastly improve if the network is mined by the insurers adequately.

Policies with OPD focus

OPD cover can be made available as a feature (of the base policy) or as an add-on that is purchased with extra cost. As a feature, Manipal Cigna provides OPD cover of ₹20,000 (₹30,000/50,000 also available) per year in its base policy; ₹5 lakh health insurance policy with a premium of ₹9,000 (30-year-old male). This covers consultation, prescribed diagnosis and pharmacy expenses (20 per cent sublimit for pharmacy).

But OPD cover is mainly provided as an add-on across other insurers. Aditya Birla’s Activ Health policies offer an option for unlimited physical consultation with empanelled doctors for ₹700 (add-on cost), on the base policy (₹5 lakh cover for ₹7,200). One can include virtual consultation option for additional ₹200 and two specialist consultation per year option for another ₹200. Niva Bupa Health Reassure plans offers an OPD add-on with access to Apollo 24*7 doctors. The teleconsultation add-on is priced at ₹1,262 (base policy ₹6,860) and whole package (teleconsultation, prescribed tests and drugs) costs ₹5,435. Bajaj Allianz OPD add-on cover (base policy ₹8,400) for ₹640 covers unlimited teleconsultation across specialties, doctor consultation of ₹2,000 and investigations cover of ₹5,000.

ICICI Lombard’s BeFit add-on for its policyholders, serviced from its app, combines OPD with wellness. Pricing of the rider starts from .₹297 with a total of six different options with the highest plan priced at ₹6,558. The plan offers virtual consultations including counselling, ambulance assistance, preventive care, wellbeing, and health management. The highest plan offers, physical and virtual consultations, pharmacy, and diagnostics services of up to ₹5,000 per year, and physiotherapy sessions as well.


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