What is OPD Expenses Cover in Health Insurance?

What is OPD Cover?

OPD cover or Out Patient Department cover is a new feature offered as a part of the health insurance policies from insurance providers such as Apollo Munich, ICICI Lombard, Bajaj Allianz and Cigna TTK. Most health insurance providers only cover hospitalization expenses and this limits the scope of cover for Out Patient Department expenses. These expenses include doctor’s consultation fees, health check-ups, pharmacy bills, dental treatment, diagnostic tests, etc.

Why one should Buy Health Insurance with OPD Coverage?

• Health Insurance plans that offer OPD cover assists the insured to claim expenses other than that incurred during hospitalization.
• Compared to regular health insurance policies, there are more tax benefits associated with these plans. Policyholders can claim tax exemption on the premium paid for such health insurance policies. There is no Tax Deductible at Source (TDS) for claims.
• In most health insurance policies with OPD cover, the insured can claim reimbursement on expenses multiple times during the policy period. Out Patient Health Services include a huge number of services and hence more transactions. This makes the monetary value of a health insurance policy with OPD cover higher than that of a regular health insurance policy.
• This policy also covers pharmacy bills and thereby assist those who have more expenses from the same.
• Regular health insurance policies determine claims and sum assured based on 24 hours hospitalization. Under the OPD Cover, the sum assured is based on the age of the insured.
• OPD expenses can be claimed within 90 days of availing the health insurance policy

Top Companies offering OPD (Out Patient Department) Cover:

Insurer and Plan Name	Overview	Features
Bajaj Allianz Tax Gain Plan	This is a family floater health insurance policy offered by Bajaj Allianz that covers hospitalization expenses as well as OPD expenses.	It offers great tax benefits to the policy holder, as provided under Section 80D of the Income Tax. The Tax Gain plan offers the insured cashless facility through 5000+ network hospitals in India. Out Patient Department expenses can be claimed quickly and easily. The expenses covered include cost of dentures, spectacles, crutches, dental treatment, dental procedures, etc. This plan also covers up to Rs. 1,000 as ambulance charges.
Apollo Munich Maxima Plan	Apollo Munich offers the Maxima Health Insurance plan that covers Out Patient Department expenses as well. It offers cashless facility for OPD expenses from authorized diagnostic centers, pharmacies, dental care centers and optical care centers.	The minimum age for entry is 91 days and the maximum age for entry is 65 years. Premium on the policy will be determined based on the age of the insured and if the policy is taken for a family, the age of the eldest insured member is considered to determine the premium. This policy also covers dental treatment and procedures, cost of eyewear, contact lenses, hearing aids, etc. Individuals or families can avail a Maxima Health Insurance plan and avail its benefits. Outpatient benefits under this plan include doctor’s consultation, pharmacy expenses, specialist services (for certain dental treatments, spectacles and contact lenses only), cost incurred for diagnostic tests, health check-up benefits for the insured who is more than 18 years old. Maternity benefits include cover for expenses incurred before and after childbirth. If the Out Patient treatment cover is not utilized during a policy year, 50% of the same will be carried forward to the next policy period.
Max Bupa Heartbeat Platinum Plan	Max Bupa Heartbeat Platinum Plan, is a comprehensive individual/ family floater plan that offers a minimum sum insured worth Rs.15, 00,000. For OPD claims made under this policy, the maximum limit is Rs. 30,000.	Maternity benefits include cover for expenses incurred before and after childbirth, cover for the newborn, vaccinations during the first year, child care cover, etc. This policy does not place a restriction on the age of entry, i.e., there is no minimum/ maximum age for entry. If the Out Patient treatment cover is not utilized during a policy year, 80% of the same will be carried forward to the next policy period. The age of the eldest insured member in the family is considered to determine the premium. This policy also offers great tax benefits to the policy holder, as provided under Section 80D of the Income Tax.
Cigna TTK ProHealth Accumulate Plan	The Cigna TTK ProHealth Accumulate Plan offers OPD cover for outpatient treatment, optical care, dental treatment, consultation fees, pharmacy bills, and so on. This policy comes with a “Personal Health Wallet” in which policyholders can keep the funds they have accumulated and use it to pay for OPD expenses.	The base cover offered under this policy offers a cover worth Rs. 5, 50,000 – Rs. 25, 00,000. The Cigna TTK ProHealth Accumulate Plan is the personal health wallet benefit option for amounts worth Rs. 20,000, Rs. 15,000, Rs. 10,000 and Rs. 5,000. The money accumulated in the wallet does not expire due to non-utilization. This amount is carried forward when the policy is renewed. The policyholder can also avail an additional benefit of 5% hike on the amount available in the wallet. You can also avail reward points by participating in wellness programs and this can then be used to add funds to the wallet or can be adjusted against your premium.