Do OPD costs fall under the oversight of your health insurance? Here is what to watch out for

 Do OPD costs fall under the oversight of your health insurance? Here is what to watch out for

OPD costs can be divided into three general categories: medical consultations, diagnostic testing, and medications. Some health insurance plans do not pay for all three of these costs. Be sure to read the tiny print before choosing the best insurance for you.

Health insurance coverage have traditionally been used to cover your hospitalization-related medical costs. However, there are now health insurance plans with built-in OPD coverage that can be utilized to cover your outpatient treatment (OPD) costs, which don't require hospitalization.

In addition to this, a lot of insurers provide what is known as an OPD rider or add-on cover that you can add to your standard health insurance policy to pay for your outpatient treatment costs.

So what does OPD normally cover for health insurers?

What is included and what is not

OPD charges generally fall into three categories: medical consultations, diagnostic testing, and pharmacy (medicines), however this varies according on the policy or rider that you have. Additionally, not all health insurance plans provide coverage for all three of these costs.

All three of these categories are covered by the Niva Bupa Health Premia (Platinum) plan for outpatient charges. Similarly, the ManipalCigna ProHealth Prime Advantage plan includes coverage for all three groups with restrictions on pharmacy costs. On the other hand, pharmacy costs are not covered by the Bajaj Allianz My Health Care Plan.

Similar variations can be found in add-on covers. With the OPD add-on insurance from Aditya Birla Health Insurance Company, you have unrestricted access to physical and/or virtual doctor consultations throughout the insurer's network of hospitals. Diagnostic procedures, however, and medication costs are not covered.

There are numerous variations of the Niva Bupa Smart Health PLUS rider. The policyholder has unlimited teleconsultations with Apollo 24 hours a day with its Best Consult and Best Care variations. However, outside of this network, consultations are not covered. Additionally, Best Consult only covers tele-consultations as opposed to Best Care, which also includes medical examinations and medications.

The Health 360 OPD add-on insurance from ManipalCigna Health Insurance Company is available in three different versions, the first of which only covers consultations; the second, both consultations and prescribed diagnostics; and the third, all three, including prescribed pharmaceutical goods.

To choose the best health plan, see also Moneycontrol-SecureNow Health Insurance Ratings.

How much insurance do you have?  

The total cost of OPD coverage may be as little as a few thousand rupees or as much as Rs 50,000 annually.

According to the image in the Health AdvantEdge policy paper from ICICI Lombard, for a base SI of Rs. 10 lakh, you receive an OPD cover of Rs. 5,000. However, if you choose a base SI of Rs. 1 crore, you receive a Rs. 50,000 OPD cover. Similar to this, the Tata Medicare Premier policy offers OPD coverage in the amounts of Rs. 5,000 for base SI of Rs. 50 lakh, Rs. 7,500 for base SI of Rs. 75 lakh, and so on.

You receive an OPD cover of Rs 15,000, Rs 20,000, Rs 35,000, or Rs 50,000 under the Niva Bupa Heartbeat (Platinum) plan, based on the base SI selected, which can be Rs 15 lakh, Rs 20 lakh, Rs 50 lakh, or Rs 1 crore.

The Bajaj Allianz - My Health Care Plan, where the OPD benefit is two times the premium, operates completely differently. For instance, if you pay a premium of Rs. 10,000, you receive an OPD cover at Rs. You can select a SI for the base policy starting at Rs. 3 lakh and going all the way up to Rs. 5 crore.

Other things to consider  

Additionally, see if any unused OPD cover funds from the prior year can be carried forward.

80 percent of the unused portion may be carried over to the immediately succeeding year under the Niva Bupa Health Premia (Platinum) plan and the Heartbeat (Platinum) plan, provided that the total amount (including the unused portion) does not exceed 2.5 times the OPD cover amount offered by these policies.

Numerous features, including teleconsultation and in-person consultation for a certain number of times each policy year, are offered by the Bajaj Allianz - My Health Care Plan. These benefits cannot be carried over to the following year if you do not completely utilize them this year. The cover intended for diagnostic testing also cannot be carried over if it is not used.

The ManipalCigna Health 360 OPD add-on cover does not provide for the carryover to the following year of any unused funds.

That being said, it should be noted that, in some situations, OPD add-on covers can only be purchased in addition to a base health insurance policy provided by the same insurer. You might only be able to add-on insurance to certain policies, even with the same insurer.

Then, there can be more circumstances. One such example is the Niva Bupa Smart Health Plus rider, which is exclusively available as an individual plan.

In addition, as is the case with Manipal Cigna Health Insurance Company, the OPD add-on cover may restrict you to the insurer's network of hospitals. Others, like Bajaj Allianz General Insurance Company, on the other hand, offer the option of diagnostic tests and consultations outside of the insurer's network of hospitals, if necessary.

Should you pick an OPD policy?

It could be tempting to choose a health insurance plan with a sizable built-in OPD benefit. However, these insurance might frequently be expensive ones with higher premiums. This could not be a cost-effective choice unless you want to take such an insurance for all of its other features. (See table earlier)

Opting for an OPD add-on cover is the alternative. However, these might only offer a few OPD cover amount options and might have a few exclusions (see table). Therefore, before choosing them, be sure that these add-on covers offer what you require.

OPD is a high utilisation product, hence the premium for this is a high percentage of the sum covered, according to Dr. Bhabatosh Mishra, Director - Claims, Underwriting & Product, Niva Bupa Health Insurance Company. This is not the case for standard health insurance policies that cover hospitalization, even when the likelihood of such an event is not very great.

Another person who makes a similar case is Nikhil Apte, Chief Product Officer of Royal Sundaram General Insurance Company, who claims that "Standalone OPD is not an insurable event as it is a reality for every household." Only probabilistic events, like hospitalizations, when everyone pays a premium but only a few need it, are covered by insurance.

He continues, "We have to manage all of our expenses within 30% (IRDAI requires general insurers to cap their expenses at 30% of gross written premiums), plus there is 18% GST, so 48 percent is already gone." Aside from this, insurers believe that such coverage may be subject to abuse because it might be challenging to monitor OPD usage. "Accordingly, OPD is not a marketable standalone offering for an insurer. Having stated that, when it is connected to a hospitalization occurrence, insurance companies are offering comprehensive OPD benefits (pre- and post-hospitalization)," adds Apte.

Dr. Mishra claims that despite the industry's progress (several OPD products have been introduced), there is still room for improvement given the demand for OPD goods.