What is OPD
Cover?
  • Avail coverage for outpatient treatments
  • Explore the eligibility criteria
  • Difference b/w OPD & Day Care Treatment
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What is OPD Cover? 

OPD treatment means the type of treatment wherein the insured visits a clinic/hospital or associated facility like a consultation room for diagnosis and treatment based on the advice of a medical practitioner. Hence, OPD cover provides coverages for expenses such as doctor's consultation fees, pharmacy bills, health check-ups, and diagnostics tests.

In comparison to other health insurance policies, the sum insured under OPD coverage is determined by the insured person's age. Health insurance with outpatient care coverage, of course, gives additional financial security.

Eligibility Criteria

There are is no specific eligibility criteria to avail of OPD benefits. Any individual who is feeling unwell can go to a doctor's clinic for consultation and treatment.

**However, the possibility is that your health insurance company may have some sort of eligibility criteria or waiting period for OPD coverage. Therefore get in touch with your health insurance provider to understand the criteria.

Benefits of Health Insurance with OPD Cover

Health ailments come unannounced, and you can never predict when you might need hospitalization or can get yourself treated without it. Therefore, it is better to be prepared in advance for both the situations. Having a health plan with OPD cover not only provides coverage but also offers several perks. Read the following points to know the benefits:

  • People suffering from chronic medical conditions such as diabetes, asthma, and high blood pressure need regular doctor consultation. The expenses of such visits get covered under OPD.
  • The minor surgical procedures that don't require hospitalization can be covered under OPD cover.
  • Policyholders are entitled to the OPD cover for the entire policy year.
  • With an OPD cover, a policyholder gets access to a wide range of clinics as well as hospitals with a consultation room.
  • Plans that cover OPD expenses provide more tax benefits in form of tax exemption on the premium paid.

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How is OPD Different From Day Care Treatments?

People often get confused in OPD & Daycare treatments. Before buying any policy, do understand how one is different from the another. Take a look at the below given comparison to get a clear picture about the two:

ParametersDay-care TreatmentsOPD Treatments
Hospitalization TypeUnder day-care treatments, the patient is required to stay in the hospital for a few hours.OPD treatments do not require any hospitalization. Patients can come, consult the doctor and can go.
Waiting PeriodsGenerally comes with a waiting of three years, which means treatment can be availed only after serving the waiting period except for any accidental injury.It comes with a waiting period of 90 days.
Sub-limitsThere are no sub-limits. Treatment costs are covered up to the chosen sum insured.Comes with a sub-limit of your overall sum insured limit.
Treatments Covered
  • Diagnostic tests & X-rays
  • Doctor's fees
  • Routine check-up, vaccination
  • Minor surgeries
  • Dental treatment.
  • Cataract operation
  • Nasal sinus aspiration
  • Glossectomy
  • Lithotripsy
  • Coronary angiography
  • Haemodialysis

Who Should Buy Health Insurance with OPD Cover?

  • Immuno-Compromised People:Having a health insurance with OPD Cover is useful for those, whose immune system is weak and they require frequent hospital visits for OPD consultations including something as basic as viral fever.
    Also, medical insurance with OPD cover is beneficial for those patients who have pre-existing medical conditions such as thyroid, diabetes etc. and require frequent medical consultations.
  • Sports Enthusiasts: If you are someone who likes to engage in physical activities or are a sports person, then you must go for a health plan that offers OPD cover. This is because while indulging in any sort of sports or fitness activities, people are very much prone to injuries that may not require hospitalization, this is why having a health plan with OPD cover will save you from such expenses.
  • Senior Citizens: Senior citizens are more prone to health ailments and are usually more likely to require OPD treatments like dental treatments and minor surgeries. Thus, it is of utmost importance for them to consider taking a health plan with an OPD cover which will help cover both regular health insurance benefits and OPD treatments. Having a health insurance which covers OPD expenses will save them from broadening their pockets during doctor's visits.
  • Working Professionals with Limited Group Medical Insurance Coverage: Most companies offer group medical insurance to their employees. However, usually, the coverage is low and people often prefer to buy another health policy for better protection. In such cases, one can go with an additional health insurance policy with an OPD cover since a lot of group medical insurance plans don't include OPD benefits.

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What Is Covered Under OPD?

A health insurance which covers OPD offers coverages against the below-mentioned expenses: 

  • Doctor's consultation fees
  • Routine check-ups
  • Diagnosis tests
  • Vaccination
  • Hearing aid
  • Minor surgeries
  • Dental treatment
  • Spectacles, contact lenses

What Is Not Covered Under an OPD

  • Treatments for beautification, purification such as plastic surgeries etc.
  • Any claim resulted due to involvement in illegal activities.
  • Any claim resulted due to substance abuse.
  • Investigational treatments or experiments.
  • Inpatient treatment, daycare procedures and naturopathy treatments.
  • Treatments related to Sterility, infertility, and other related conditions.
  • Self-inflicted injuries.

Inclusions and Exclusions of an Outpatient Insurance Cover in Health Insurance

The various inclusions and exclusions of OPD health insurance are mentioned below

Inclusions

Cover for Doctor’s fee

Diagnostic expenses cover

Medicine bills cover

Regular OPD Visits

Tax Deductible

OPD treatments

Hearing aid

Minor surgeries

Dental treatment

Exclusions

Treatments for beautification, purification such as plastic surgeries, etc.

Any claim resulting due to involvement in illegal activities.

Any claim resulting due to substance abuse.

Investigational treatments or experiments.

Inpatient treatment, daycare procedures, and naturopathy treatments.

Treatments related to Sterility, infertility, and other related conditions.

Self-inflicted injuries.

International OPD treatments availed

Any treatment related to fertility medical issues

Pregnancy/Miscarriages

Treatments for rejuvenation/wellness

Conclusion

There are several illnesses that can be treated only by the medicines prescribed by doctors. Sometimes, these doctor's consultations may continue for a longer period, often burdening your pockets. Thus, before buying a health plan, make sure that the OPD is covered under the same, and get your consultations, diagnoses, and treatments covered under a health plan.

What is OPD Cover?:FAQs

1. Why should I get health insurance with an OPD cover?

With a continuous increase in the healthcare facilities, a normal doctor consultation from a private hospital can cost somewhere between Rs.700- 1000. This means for a normal viral fever, you will have to spend almost 4-5k which will include all the tests & consultations.

To protect you from such expenses, it is better to have health insurance with an OPD cover.

2. Is there any limit to avail OPD benefit under a medical insurance with OPD cover?

Yes, the OPD treatments come with a sub-limit. Go through the policy wordings carefully to know the OPD limit of your policy.

3. How can I buy an OPD health plan?

Get in touch with the experts at PolicyX.com. They will help and assist you with all your queries.

4. What is the difference between OPD health insurance and daycare treatments?

Both are part of a health insurance plan however they are technically different as Day care treatments require hospitalization for not more than 24 hours while for an OPD treatment, you do not require hospitalization at all.

5. Are OPD health insurance eligible for tax benefits?

Yes, OPD cover health insurance plans are eligible for tax deductions under the Income Tax Act.

6. When can an insurance holder utilize OPD health insurance?

Insurance holders can utilize OPD health insurance when they do not require hospitalization, or if they have undergone surgery or major treatment and want to go for follow-ups and health check-ups.

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Reviewed By : Naval Goel

Naval Goel is the CEO & founder of PolicyX.com. Naval has an expertise in the insurance sector and has professional experience of more than a decade in the Industry and has worked in companies like AIG, New York doing valuation of insurance subsidiaries. He is also an Associate Member of the Indian Institute of Insurance, Pune. He has been authorized by IRDAI to act as a Principal Officer of PolicyX.com Insurance Web Aggregator.