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OPD Cover in Health Insurance: Check Coverage and Benefits

Team AckoAug 10, 2021

Even though in-patient medical expenses tend to be significantly higher, outpatient costs can accumulate over the year and can burn a hole in your pocket. A recent survey by ET Prime revealed that nearly 62% of healthcare costs in India are towards Out-patient Department (OPD) expenses. With rising healthcare costs, it is wise to choose a medical insurance plan with OPD cover. This article helps you understand the benefits of OPD cover in Health insurance.

OPD Cover with Health Insurance

What is OPD in Health Insurance?

Not all medical issues require hospitalisation. For example, you may need to visit the OPD to treat a minor illness or injury. During such instances, you may visit the clinic or the OPD of the hospital, get the doctor to assess the medical issue, may require a diagnosis through a lab test, and buy medicines at the pharmacy to treat the medical problem. For these services, you pay for doctor consultation fees, lab tests, and medicines.

Regular health insurance plans do not cover such expenses, leaving you financially burdened. Thankfully, new-age health insurance companies (such as ACKO) have designed policies that include coverage for OPD expenses. The OPD cover assists the insured in claiming expenses that are not covered as an in-patient.

Benefits of OPD Cover in Health Insurance Policy:

Here are the advantages of OPD cover in Health Insurance Policy.

  • Claim for medical expenses incurred without being hospitalised.

  • It covers doctor’s consultation fees, diagnostics charges, and pharmacy bills.

  • Beneficial for patients who need regular OPD visits.

  • It helps save on income tax deductions.

  • Reduces additional financial burden for those with chronic conditions or pre-existing illnesses that require multiple OPD visits.

Inclusions of an Outpatient Insurance Cover in Health Insurance:

Here are the coverage details of OPD cover in medical insurance.

  • Doctor consultations

  • Diagnostic tests

  • Pharmacy expenses

  • OPD treatment

Exclusions of an Outpatient Insurance Cover in Health Insurance:

Here are the exclusions of OPD cover in medical insurance.

  • Facilities or services availed for rejuvenation, pleasure, etc.

  • Treatments for beautification, purification, detoxification, panchakarma, etc.

  • Cost of spectacles, lenses, implants, hearing aids, prosthetic devices, braces, etc.

  • OPD treatment outside India.

  • Routine examinations or preventive health check-ups.

  • Vaccination including inoculation and immunisations except in case of post-bite treatment such as a dog bite.

  • Investigational treatments or experiments.

  • Sterility, infertility, and other related conditions.

  • Complications arising out of pregnancy, miscarriage, etc.

  • Dentures, dental treatment, and surgery of any kind.

Claim Settlement Process:

Here are two types of processes to raise a claim for OPD expenses.

  • Reimbursement Claims: Upon completing the OPD treatment, you need to upload the bills and all relevant documents by logging in to your account via ACKO’s website or mobile app to process the reimbursement.

  • Cashless Claims: You can avail of OPD treatment at any of the ACKO’s network hospitals or Day Care centers by submitting your e-health card and requesting to initiate the cashless claim.

Difference Between Day Care Treatment and OPD Treatment:

Day Care treatment and OPD treatment are similar. However, there is a slight difference between the two as they differ in the technical aspects. Here are the differences between the two types of treatments.

Day Care Treatment OPD Treatment
It requires hospitalisation not more than 24 hours. It does not require hospitalisation.
Settlement of claims will not be honoured if hospitalisation is not more than 24 hours. Settlement of claims will be honoured only for non-hospitalisation.

Example: A root canal treatment that does not require hospitalisation is categorised as OPD treatment. In contrast, a dental surgery needed due to an accident and required hospitalisation of fewer than 24 hours can be classified as Day Care treatment.

Difference Between Out-patient Department (OPD) Treatment and In-patient Department (IPD) Treatment:

There is a clear difference between the two types of treatment. Here are the differences between OPD and IPD.

OPD IPD
A visit to a doctor or a clinic. Admitted for appropriate care and attention.
It does not require hospitalisation. It requires hospitalisation for more than 24 hours.

Example: A root canal treatment is considered OPD treatment, while a heart surgery requiring hospitalisation for more than 24 hours is regarded as an IPD treatment.

Why Should You Get a Health Insurance with an OPD Cover?

Here are the reasons why you should consider buying medical insurance with an OPD cover.

  • A recent survey by Practo revealed that visits to the doctor or clinic have increased from 2.7 times in 2017 to 3.2 times in 2018.

  • OPD expenses in India account for nearly 62% of the total medical care expenses compared to In-patient Department (IPD) expenses.

Who Should Buy a Health Insurance with OPD Cover?

Health insurance plans that provide OPD coverage are helpful for those who are looking to extend the primary plan’s coverage apart from coverage for hospitalisation. If you fall into any of the three categories, you should consider Health Insurance Plan with OPD Cover.

  • People in the age group of 25 to 40 years who may not use the in-patient hospitalisation more than out-patient services.

  • Senior citizens who may require regular minor surgeries, root canal treatment, etc.

  • Fitness enthusiasts who are considered highly fit and may not use in-patient services more than OPD for workout-related injuries.

Frequently Asked Questions:

Here are some of the most commonly asked questions about health insurance plans with OPD cover.

Can I avail of tax deductions on health insurance plans with OPD cover?

Yes, you can claim tax benefits on health plans with OPD cover under Section 80D of the Income Tax Act.

When are the instances when I can utilise my OPD cover?

You can use the OPD cover in the health insurance plan for minor surgeries or treatments that do not require hospitalisation.

Can I buy an insurance plan that covers only OPD treatment?

It depends on the insurance company and the plans they offer. You need to review the plans before you buy the plan that provides coverage only for OPD treatment.

How do I buy health insurance with OPD cover?

OPD cover in health insurance is offered as an add-on cover at an additional premium. However, it may differ between insurance companies. For example, some plans are bundled with OPD cover, while other plans offer OPD cover as an add-on. Therefore, it is prudent to check the coverage details so that you can make an informed decision.

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