Explained: Why you should get OPD cover with health insurance?

The COVID-19 pandemic, which infected over 200 million people in the world and 32 million in India alone, has brought the importance of having a health insurance policy back in focus. Having a health insurance cover is critical given the ever-increasing costs of medical care as well as a rise in lifestyle-related ailments that are on a rise due to our sedentary lifestyle.

However, most people do not know that not all treatment costs are covered by every health insurance policy. While a regular health insurance policy covers medical care costs in case of hospitalization, the patient does have to incur some out-of-pocket expenses in such cases as well. Moreover, when it comes to costs related to medical care that do not involve hospitalization of the patient, they are usually not covered by health insurance policies.

As per various estimates, out of all medical costs incurred by an individual, only up to 60 percent are covered by health insurance policies, even taking into account the protection offered by a comprehensive health cover. The rest 40 percent has to be paid by the individual out of his or her own pocket.
As per media reports, in the case of COVID treatment, out-of-pocket expenses were in the range of 30-50 percent of the total amount spent on the COVID-19 treatment. Moreover, Out-Patient Department (OPD) expenses — expenses incurred where the treatment and diagnoses are done during the visit to a clinic or a consultation room at a hospital — are not covered by such policies either. So even if you have bought a comprehensive health insurance policy, you are not compensated for consultation fees, health check-ups, pharmacy bills, dentist treatments and diagnostic tests, among others.

The good news is that many insurers are now redesigning their policies to address these issues, and now there are plans available that cover OPD expenses to a certain extent, going beyond the expenses incurred in case of a hospitalization. Care Health Insurance’s Care Plus plan covers out-patient consultations/ out-patient dental and ophthalmic treatments that give ease to your pocket. For now, the cover is available for OPD expenses up to Rs 3,000.
What expenses are covered under OPD health covers?

Doctor’s Consultation

When you make that occasional visit to the doctor to seek medical advice, be it for a cold or fever, or a serious rash, a regular health insurance policy will not cover the consultation fee of the doctor. However, if you have opted for the OPD cover, you do not have to worry about this expense, as your policy would take care of that. This is even more useful in family health insurance plans with children also covered under the policy, as doctor’s visits are quite frequent in such cases.

Diagnostic and Investigative Tests

An OPD cover also compensates for the costs incurred in case of diagnostic tests like blood tests, stool tests, CT scans, X-rays, sonography, and MRI, among others. This is irrespective of whether you are diagnosed with an ailment or not. As long as your doctor prescribed the tests for investigation and diagnosis, your policy would cover these costs up to the prescribed limit.

Pharmacy Expenses

Another expense that can add up to a lot, but is not covered in a regular health insurance plan is the pharmacy expenses on those prescribed medicines. With an OPD cover, even these expenses are taken care of by your policy.

Dental Procedures

Health insurance policies usually do not cover medical costs incurred in relation to dental treatments like fillings, root canal treatment, tooth extraction, etc. In fact, even those policies with cover listed daycare treatments, do not include dental treatments. However, new-age plans with OPD cover come with protection against dental treatments as well, including the cost of dentures to a certain limit.

Eyewear and Hearing Aids

Just like in case of dentures, there are certain limits but OPD cover policies do cover the costs of hearing aids and eyewear like spectacles and contact lenses. Therefore, if you have this cover, you need not bear the entire cost if you are prescribed glasses or hearing aids. Your insurance will take care of the same.
There are immense benefits of OPD expenses coverage in health insurance. It is especially useful for families with kids, and for patients who require frequent visits for OPD consultations. People suffering from chronic medical conditions like asthma, diabetes, arthritis, thyroid ailments etc., can stand to gain a lot from such a health cover. From covering something as basic as a viral fever to complex dental treatments and other daycare procedures, OPD cover protects you from the medical expenses that can add up to a lot over the long term. It also compensates you for hefty pharmacy bills.

Most insurers have certain limits to the extent of which the OPD claims can be compensated. In addition, many insurers offer the benefit of rolling over a part of the OPD cover to the next policy year if it goes unutilized.

The author, Amit Chhabra, is Head-Health Insurance at Policybazaar.com. The views expressed are personal