The recent IRDAI circular on insurers leveraging a central registry of healthcare professionals may promote wider acceptance of OPD (outpatient service) covers in health insurance. With that in mind, we take a look at what constitutes OPD coverage and the insurers that offer it.
In medical insurance, outpatient service or OPD consultation is the shortest of the stick. Fewer policies focus on covering OPD consultation fees. Extending health insurance to adequately cover OPD visits may be useful for some insured persons whose medical care involves frequent visits rather than hospitalization. OPD care is a critical step in the medical care cycle and faces medical cost inflation and patient affordability issues, just like hospital care. This can be addressed by health coverages that focus on OPD consultation in addition to inpatient coverage.
Basic Principles of OPD Coverage
Under typical OPD coverage, consultation, as well as diagnostic tests/prescribed medications, are covered with limits (ranging from ₹1,500 to ₹20,000 per year) under the overall OPD coverage. ‘Health Insurance. Day care procedures (cataracts, orthopedic alignments, dialysis) are different from OPD coverage and may fall within the scope of primary health insurance coverage anyway. Likewise, wellness and aesthetic consultations are generally not covered by OPD coverage.
The OPD coverage requirement for insureds is not defined by age, illness or other demographic markers, but is an individualized consideration. The requirement can be assessed based on past disbursements for medical consultations and the timing of future consultations. For specific conditions, diabetes, cholesterol, kidney conditions, skin conditions, it is necessary to confirm coverage under OPD (in policy documents) before considering the insurer.
The other condition to ponder and confirm is waiting times, even for pre-existing conditions. Specifically, major insurers including Aditya Birla and Manipal Cigna have specified Day 1 OPD cover in their policy wordings and it may be beneficial to confirm similar terms with any other insurer as well. The descriptions will also mention telemedical/virtual consultations, which are different from physical consultations. As expected, the premium will be for in-person versus telemedical consultation and the latter is much more common in policies, even those that may not be focused on OPD coverage.
Insurers usually provide a set of doctors/consultants to offer cashless OPD reimbursement. The insurance regulator, IRDAI, has proposed that insurers leverage the registry of healthcare professionals to create a network of healthcare professionals to provide DPOs. Among the many benefits, simplified OPD service delivery with cashless option can improve significantly if the network is properly operated by insurers.
OPD-oriented policies
OPD coverage can be made available as a feature (of the base policy) or as a purchased add-on at an additional cost. As a feature, Manipal Cigna offers OPD coverage of ₹20,000 (₹30,000/50,000 also available) per year in its basic policy; Health insurance policy ₹5 lakh with a premium of ₹9,000 (30 year old male). This covers consultation, prescribed diagnosis and pharmacy fees (20 percent pharmacy sub-cap).
But OPD cover is mainly provided as a supplement by other insurers. Aditya Birla’s Activ Health policies offer unlimited physical consultation option with licensed doctors for ₹700 (additional cost), on the basic policy (₹5 lakh cover for ₹7,200). One can include the virtual consultation option for an additional ₹200 and two specialist consultations per year for an additional ₹200. Niva Bupa Health Reassure plans offer OPD add-on with access to Apollo doctors 24*7. and medicines) costs ₹5,435. Bajaj Allianz OPD Supplemental Coverage (₹8,400 basic policy) for ₹640 covers unlimited teleconsultation in all specialties, ₹2,000 doctor consultation and ₹5,000 survey coverage.
ICICI Lombard’s BeFit add-on for its policyholders, managed from its app, combines OPD and well-being. Pricing for the rider starts from ₹297 with a total of six different options with the highest plan priced at ₹6,558. The plan offers virtual consultations including counselling, ambulance assistance, preventative care, wellness and health management. The highest plan offers physical and virtual consultations, pharmacy and diagnostic services up to ₹5,000 per year, as well as physical therapy sessions.
Posted on November 26, 2022
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