Should You Buy Health Insurance With OPD Cover? Know Benefits, Coverage And Exclusions Before Buying

An OPD cover health insurance refers to an insurance rider that covers all hospital expenses, such as routine health check-ups or doctor consultations.

Before we skip to the answer of whether you should buy an OPD cover, let’s picture this. You just missed your annual health checkup because it would have cost you ₹5,000 out of pocket. Six months later, you’re hospitalised with a health condition that you could have prevented with early diagnosis. And now, your hospital bill stands at ₹2 lakh, with a week of loss of pay. An OPD cover could have covered all of your healthcare expenses without letting you postpone or avoid your early diagnosis. Let’s understand this in detail.

What Is OPD Cover In Health Insurance?

OPD, or Outpatient Department coverage, covers your everyday healthcare expenses whenever you need to visit the hospital for diagnosis or a medical checkup. When you compare OPD cover to traditional health insurance, there is a difference. A traditional health policy covers hospitalisation costs whenever you are hospitalised, and OPD cover means financial protection for any petty and trivial health expenses.

OPD cover helps Indian startups and MSMEs that operate on a lean budget, take care of their employees at a much lower premium. Insurance with OPD cover is a strategic planning for corporates, as it helps them to care about the entire team's regular health expenses at just a small annual premium.

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Importance of OPD Cover

A study conducted by NGO Agewell found that 48.6% senior citizens don’t visit healthcare centers due to high expenses. The right diagnosis at the right time can cause a major impact and avoid a costly hospitalisation later. Diseases such as hypertension or diabetes can kick in early for working people, resulting in them taking multiple sick leaves or planning early retirement. Here are the reasons why you should consider buying an OPD cover:

Regular Healthcare Expenses Covered

Whether your company is a startup or a mid-sized company, having healthcare for the daily medical needs of your team is a necessity now. Imagine having team members often applying for sick leaves during a month, which hits both their productivity and disrupts teamwork. A health insurance with OPD cover offers complete coverage for these day-to-day medical expenses, such as consultation fees or dressing a wound.

Care For Chronic Patients

Urban people have a higher chance of being a chronic patient, according to a survey. The survey shows that urban populations are 1.15 times more exposed to chronic diseases than rural populations. By having an OPD cover, you can duly protect your team who works right within urban centers, without battling the high cost of urban healthcare.

Complete Team Coverage

Covering the routine healthcare expenses of an entire team is hefty unless you are taking OPD cover. The benefit of an OPD health cover is that it provides complete coverage for your team so that they can focus on their work and not worry about paying from their own pockets. Most of the high-growth companies offer multiple perks, including insurance to their employees, as per research results .

Early Diagnosis Covered

Many of us can avoid complicated health problems if we take timely actions, such as diagnosing our health problems in time. Routine health checkups can save your team from burning out on costly healthcare expenses, which is why an OPD cover insurance is of prime importance. By having an OPD rider in insurance, your team can effectively get their monthly healthcare checkup and get early detection for possible health fatalities.

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Eligibility of OPD Cover

OPD coverage extends to most employees who are aged 18 years or age, and have valid identity proof. There are certain eligibility criteria that one needs to consider before buying an OPD cover; here are they:

Age Range

The insured needs to be an adult and at least 18 years of age. Usually, most insurers offer an OPD cover within the age of 18 - 65 years, although this differs based on the insurer and the policy coverage. The age for entry and renewal of policy varies, and may not be consistent across every insurer.

Renewal Details

The eligibility for policy renewal is different. Your insurer will often state the renewal eligibility, such as age and renewal premium, within the policy during the first time you purchase it. You can also discuss the renewal eligibility with your insurer by directly contacting them.

Health Diagnosis

Before purchasing an insurance with OPD cover, your insurer may ask for health reports stating your current health condition. Your current health reports will help the insurer to clearly understand your health risk and underwrite the correct premium.

Required Documents

These are the documents that you would require before purchasing an OPD cover in your health insurance plan:

• Current healthcare reports
• Medical prescriptions and bills
• Identity proof (Aadhar Card and PAN Card) Some insurers may ask for other documents too, which may include details of family members, proof of income in case the policyholder is an income earner, or runs a business.

Network Hospitals

Different policies have different empanelled hospitals, which depend on which insurer you have chosen. Many networked hospitals provide different OPD coverage, which you need to discuss with your insurer before purchasing insurance.

Exclusions

An OPD cover may not cover some specific cases of healthcare, such as a critical illness such as sinusitis, or a pre-existing disease condition. Additionally, each insurer has a specific list of day care & OPD treatments that are covered. You can take up a critical illness rider to get covered for all types of critical health conditions.

Main Benefits of OPD Cover Health Insurance

Employees can often fall prey to chronic and lifestyle diseases, such as viral fever or conjunctivitis. Recently in Patna, cases of viral fever have risen by 30-40%. This creates major roadblocks for employees, as they often have to take sick leaves or sometimes even weekly breaks due to constant disruption in health.

Here are the 3 benefits of having an OPD coverage:

OPD Cover Builds Culture of Prevention

As a founder and HR manager, you can build a culture of care and resilience with small steps, such as regular health screenings that let employees avail free health checkups. Already, multiple companies have taken up annual health check-ups, quarterly dental visits, and routine eye examinations as a part of their workforce retention policy.

Protects PED Conditions

Most cases of pre-existing diseases, such as diabetes, require frequent laboratory testing. Having an OPD health insurance reduces the pharmacy cost and lets the employee go for repetitive testing without paying out of their own pocket.

Early Flagging of Health Problems

Prevention is indeed better than cure, as early prevention can save you lakhs and critical health conditions. Many employees tend to postpone or avoid their routine health checkups because they cannot afford the expenses. Early detection of these healthcare problems with an OPD cover is a strategic way to prevent the onset of a health calamity.

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Types of OPD Expenses

Depending on the purpose and frequency of the OPD, we have classified these 4 different types of OPD expenses.

Consultation Expenses

A large part of the OPD expenses is doctor consultation. For example, a diabetes patient visiting for a weekly checkup is a clear example of consultation expense. This includes general physician visits for common ailments, specialist consultations for specific conditions, and follow-up appointments.

Diagnostic Treatments

Healthcare has evolved by a greater margin, and physicians now rely heavily on tests and scan reports. Repeated scans can financially impact anyone, which is why health insurance with OPD cover is the best option. Blood tests, X-rays, ECGs, and even advanced imaging are classified as diagnostic treatments.

Pharmacy Expenses

Pharmacy expenses account for a larger share of the average household budget in India. For example, prescribed medications for outpatient treatment or weekly medications in case of chronic conditions. Pharmaceutical expenses can quickly accumulate if one keeps postponing them, as they usually contain necessary medical expenses.

Therapeutic Treatments

Physiotherapy sessions, or minor treatments such as bandaging or administering injections, are occasional treatments in OPD. For example, in the case of Type II Diabetes, the patient needs periodic injection treatment.

ENT and Optical Treatments

ENT treatments are usually small and low-budget treatments that require time-to-time administering of medicines and diagnosis. For example, if a team member suddenly needs an eye examination and a routine check every 2 weeks, it is a recurring OPD expense.

Inclusions of OPD Cover

Here is a concise list of all the inclusions of an OPD cover in the healthcare industry.

Covers Consultation Expenses

Most OPD plans cover consultation expenses with general practitioners and specialists. This includes both physical and teleconsultations as well.

Covers Prescribed Medicines

Prescribed medicinal costs are also covered in the OPD cover, which is a great benefit to all those who usually spend more on repetitive medications. As India’s healthcare inflation is soaring, OPD covers medication costs fully.

Diagnostic Expenses

Pathological tests, including complete blood counts, hormonal tests, and a few more, are covered with diagnostic expenses. Some insurance policies also offer coverage for advanced diagnosis costs too under OPD cover such as X-ray and ultrasound scans.

Annual Health Checkups

Annual health checkups may include vaccination coverage, eye and dental checkups, and other preventive checkups. Chronic patients especially benefited from this, as annual health checkups without OPD can hurt their pockets. Some progressive policies even cover nutrition consultations and wellness program.

Exclusions of OPD Cover

Apart from reading the inclusions, you also need to understand the exclusions of an OPD cover health insurance.

No Coverage For Cosmetic Procedures

Procedures done for aesthetic enhancement, which include cosmetic surgery, teeth whitening, and anti-ageing treatments, are not covered.

Self-Inflicted Injuries Are Excluded

You cannot claim OPD cover for treatments for attempted self-harm, self-inflicted injuries, and deliberate substance abuse. This also includes rehabilitation program for addiction, where you cannot claim OPD cover.

Experimental Treatments Are Excluded

Any treatment that is experimental in nature or is new to the medical field is not covered. This includes any unproven treatments or experimental therapies that are still in progress and are not officially recognised.

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How To Choose The Best OPD Cover?

Many companies and employers find it difficult to choose the right OPD cover for their team. Even individuals who are looking for the best health insurance with OPD cover, find it difficult to select the most preferable insurer. You can look at these factors before dedication to buy your OPD cover:

Match Coverage Amount With Expected Healthcare Cost

You can assess the coverage amount with the expected healthcare costs. For example, manufacturing workers need higher diagnostic and physiotherapy cover as compared to a tech team. You may assess the general health risks in your industry to understand the coverage amount for health risks.

Understand Coverage Limits

Always know the coverage limits, and find out what the sub limits and overall coverage are provided. Some policies offer attractive general sub-limits but restrict critical healthcare categories such as specialist consultations.

Consider Premium Costs With Expenses

Compare the premiums against the benefits you’ll get from the OPD cover. Investing ₹200 per employee as OPD cover that excludes dental treatment is better than investing ₹500 per employee in OPD with dental care. You’ll need to perform a detailed cost-benefit analysis to determine the premium plan.

Research Claim Settlement Profile

Always research the insurer's claim settlement ratio before purchasing an OPD cover. Insurers that have a higher claim settlement ratio are more preferred by companies because of their easy and quick settlement process, hence, research about these insurers. In addition to this, inquire about the total time taken by them, the number of claims settled annually, and review their customer complaints too.

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Conclusion

India’s workplace ecosystems are evolving at an after rate. As more and more urban people are becoming the victims of lifestyle diseases, constant health diagnosis is the only option out. Having an OPD cover health insurance is thus a necessity, especially for employees and smaller teams where a single employee has to wear multiple hats. With OPD cover, teams become agile and more protected as they don’t have to compromise on their health checkups. Understanding your company’s strength, team size, and specific health needs can help you choose the best OPD cover for your team.

Your business shouldn’t suffer because your employees are having sick days. Building a productive and healthy team starts with building a culture where health is prioritised. With Group Health Insurance, you can cover the entire team at minimal costs. At Covrzy, you get to select the best plan according to your team size, with complete customization. Book a free call with us at +91 9354963947 or reach out to [email protected].