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Health Card Vs Health Insurance With OPD Coverage

Is it Wise to Choose a Health Card Over OPD Insurance?

Health insurance is inevitable in today's inflation hit age. Medical costs are indeed rising at an unabated pace but have you ever wondered your health plan might as well have considerable gaps. Even a proper health policy will not pay for a tooth filling or a broken finger.

Moreover, the cost of dental treatment, diagnostic tests, periodic doctor consultation, preventive check-ups, medicines and medical equipment, called as out-of-the pocket expenses, can disturb your savings routine.

Also, is it OK to pay Rs 15,000 more every year towards your health policy to seek an extra OPD (out-patient department) benefit of only Rs 12,000?

Insurance, a costly affair:

There are health plans in the market that cover both hospitalization and OPD treatment costs on a cashless basis in network hospitals and clinics. There is even coverage for pharmacy bills, diagnostic tests, outpatient dental treatment, contact lenses, spectacles and health checkups. A 3 lakh cover under any company's standard health plan, costs Rs 8,000 for a family of four (two adults and two children, with the eldest member being 35 years), a similar coverage under the plan including OPD treatment would cost you an astonishing Rs 32,000. The rider included features like doctor consultations are restricted to eight per year and there is a sub-limit of Rs 7,000 on various expenses, including diagnostic tests, pharmacy bills, dental treatments and eye care (spectacles and contact lenses).

Let us compare the costs of a health card with Health Insurance with OPD Coverage

Health Card

Health insurance (with OPD)

Cost- Rs.8000

Cost-20,000 (Additional cost with OPD)

Basic Annual Expense

Doctor consultation: 1000X12=12,000

Cost of medicines:1000X12=12000 .

Annual health check up for 2: 5000X2 = 10,000

Dental treatment: 75,00X2= 15,000 = Rs.49,000

---DO----

Discount/reimbursement (flat 30% on Rs. 49,000) =14,700

Discount/reimbursement = Rs. 17,200

Out of pocket expense = Rs. 42,300

Out of Pocket expense= Rs.51,800

 

The exclusions list for health plan with OPD is quite lengthy. Expenses, such as dental treatment, spectacles and contact lenses, hearing aids and other external medical equipment or devices, X-ray and laboratory examinations and investigations, vaccination (unless it is part of post bite treatment) and treatment for any psychiatric illnesses are not covered.

An OPD cover is costly. According to Health insurers, out-patient healthcare services and their coverage typically involves a huge number of transactions. The chances of a person to use the cover multiple times throughout the policy period are also more. Which is why, the monetary value that a customer can get from such a policy is higher than a basic health insurance policy.

Because of higher assumption on incidence rates (nearly 100%), the OPD premium is usually more than 50% of the sum insured and, with increasing age, becomes more than or equal to the sum insured.

Economical Alternative:

Discount cards or health cards are in no way a replacement for hospitalization cover, but are exclusive schemes that particularly give you discounted rates on medical, health and drug expenses for a monthly or annual membership fee. Healthcare plans help members save on medical expenses, with emphasis on pre-hospitalization, but also cover post-hospitalization costs. Offerings, such as discounts on dental treatments, pathology and radiology expenses and doctor consultations, are not covered under a health insurance policy. In case of a health card plan, there are no caps or sub-limits.

Health cards cover almost all healthcare expenses, including cosmetic treatments. It is also of huge help to high-risk people, such as those with pre-existing ailments, and those who are refused health insurance, especially senior citizens, who face refusals or have to shell out huge sums of money as premiums for a policy surrounded with lot many clauses and exclusions.

While a loyalty programme from a hospital chain, such as Apollo, Max or Fortis, will limit your options to the concerned group's facility, a health card from an independent company that has a tie-up with multiple hospitals, nursing homes, individual medical practitioners, pharmacy chains, pathology labs and diagnostic centers gives more flexibility of choice.

IHO (Indian Health Organization) is one company that provides these cards. Besides that there are WizzCare, Sharak Healthcare and EasyLife Care (operates only in Delhi/NCR) that offer it.

The membership fee of these cards ranges between Rs 1,000 to Rs 8,000 depending on the plan you choose and the number of members registered. A basic plan provides a discount of 15-30% on consultations and 10-20% discounts on OPD treatments and procedures at hospitals. For dental care, you get facilities of free check-ups and up to a 50% discount on the total cost of treatment.

There are also offers where you can avail up to 50% discount on doctor consultations at a few network clinics. There are some special add-on benefits as well, including 24x7 diala-doctor and chat service, free second opinion prior to a critical surgery, discount on ambulance charges and online tools like symptom tracker and health records log.

There are concessions offered by companies on 'wellness services', such as diet programmes and spa treatments, and alternative treatments, such as ayurveda and homoeopathy. Discounts of up to 40% can be availed on cosmetic treatments and up to 35% concession on spa packages.

Word of Caution:

Insurance, as we all know, is a regulated industry, whereas a health card provider isn't subject to face any restrictions from a regulated body. Therefore all the grievances would have to be addressed before a consumer court. It is, therefore, asked of you to gather enough information about the company's background before buying a membership. Is it a registered company? For how long has it been in business? Ensure it has tie-ups with couple of reputed names in your city. If the company is not keen on disclosing the network size and partnerships, it would perhaps be wise to check out a customer loyalty membership of the hospital in your vicinity.

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