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    Should you buy OPD insurance cover?


    There is a need for insurance plans that take care of outpatient department (OPD) expenses. However, OPD products have so far failed to become popular due to various reasons.

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    Out-of-pocket medical expenses account for 62% of all healthcare costs in India. So there is a need for plans that take care of outpatient department (OPD) expenses. However, OPD products have so far failed to become popular due to various reasons. They are seen as tax-maximising tools, where the additional bills served to exhaust the Section 80D limit on health premiums paid. Moreover, determining the authenticity of bills was a concern, making the claim settlement process tedious.

    Newer is better
    Now, companies like Apollo Munich and Max Bupa have rolled out products with features like cashless OPD claim settlement, setting off OPD benefit against future premium payments and so on. ICICI Lombard has tied up with health-tech portal Practo to settle cashless OPD claims under group policies.

    “The new versions are powered by tech-enabled infrastructure and service provider networks built by healthcare startups,” says Mahavir Chopra, Director, health, life and travel insurance, The entry of startups facilitating booking of appointments with clinics and diagnostics centres, and payments, has made it easier for insurers to administer claims.

    While some challenges persist—mainly with healthcare providers who still use traditional billing methods—the overall environment has turned conducive for OPD plans. “Every new concept faces challenges. Weaving doctors, diagnostic centres, pharmacies and other providers through technology into working together on a payer-funded cashless arrangement is a new concept,” says Sanjay Datta, Chief, underwriting, claims and reinsurance, ICICI Lombard.

    What you stand to gain
    The OPD benefits come in several shapes and sizes. Apollo Munich’s Health Wallet pays for OPD expenses in the form of reserve benefit. It can be used to pay for pharmacy bills, dental treatment, diagnostic tests, consultations and so on. “After five continuous renewals, it can be utilised for paying 50% of the premium. The unutilised benefit gets carried forward to the next year and gets a cumulative bonus of 6%,” says Antony Jacob, MD and CEO of Apollo Munich. The amount spent is reimbursed.

    Max Bupa’s GoActive policy pays for annual check-up to the extent of Rs 2,500 per adult, diagnostics and 10 cashless/reimbursable OPD consultations (capped at Rs 500-600 per consultation) a year through Practo’s network. Universal Sompo’s OPD benefit covers spectacles, contact lenses and hearing aid, and is built into its flagship health policy. “It comes with a waiting period of three years with no extra premium. The sub-limit ranges from 1% of the sum insured, with a maximum limit of up to Rs 7,500 as per the plan opted,” explains O.N. Singh, Chairman, Universal Sompo. Policyholders can avail this service by submitting original prescriptions and bills.

    Premiums of OPD plans are substantially higher so analyse costs before buying
    Premium inclusive of all taxes. ICICI Lombard Complete health insurance (Option A) Reimburses expenses incurred as outpatient as per plan chosen. Apollo Munich Health Wallet has separate sum insured—reserve benefit—that can be used for opd expenses. Max Bupa GoActive has capped per opd consultation fees at Rs 600 (Zone 1) & Rs 500 (Zone 2) Source: Coverfox

    Then there are existing products from ICICI Lombard—an OPD add-on—and Star Health, where the OPD component depends on the premium slab and sum assured. For instance, if you choose a sum assured of Rs 5 lakh and a premium slab of Rs 15,000 under Star Health Gain policy, your OPD element will be Rs 8,635. It also comes with a carry forward benefit. “Carry forward facility for unutilised balance to the next year of insurance encourages customer towards a need-based usage,” says Anand Roy, ED and CMO, Star Health & Allied Insurance.

    Are benefits worth the costs?
    While OPD coverage is a valuable benefit, it comes at a significantly higher price. Analyse whether the utility value justifies the cost, keeping your health requirements and age in mind. “One should calculate his own or family’s likely usage of primary healthcare and carry out a cost-benefit analysis,” says Chopra.

    For example, a 35-year-old choosing to buy Apollo Munich’s Health Wallet policy with a sum insured of Rs 5 lakh will have to pay Rs 14,224 against Rs 8,431 under its Optima Restore plan. The value of OPD reserve benefit in the former is Rs 5,000, which means you would be paying Rs 6,000 to get a benefit of Rs 5,000. However, you are allowed to carry the unused benefit forward. Also, plans that pay for hearing aids and spectacles are useful for older people, given that such tools are not covered under regular health plans.

    Be wary of sub-limits and restrictions on availing the services only in network hospitals. Instead, you can simply park funds in a fixed deposit or a liquid fund to take care of inflation and recurring medical expenses.


    The Economic Times

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