Mapping OPD covers

If you have an insurance policy or are planning to buy one, you will come across the term out-patient department (OPD). These are cases where you are treated for your illness without any hospitalisation. Most of you might be taking care of your OPD treatments through your out-of-pocket expenditures as getting an insurance cover for OPD expenditures is a difficult task due to the paucity of good, comprehensive and affordable OPD covers. However, insurance companies do provide coverage for it. Let’s understand how:

There are two kinds of OPD coverage in the market. “It is either a part of your base plan or it comes as a separate rider. Typically, health insurance policies give coverage for inpatient, day-care hospitalisations and whenever the inpatient hospitalisation claim is payable. The insured gets OPD benefits such as medicines, consultations and diagnostic tests under pre- (30-90 days) and post- (60-180 days) hospitalisation,” said Amit Chhabra, head - health insurance, Policybazaar.com. You can also get separate defined OPD limit apart from OPD being covered under inpatient and pre- and post-hospitalisations.

“However, policies with separate OPD coverage are at relatively higher premium compared with policies giving basic inpatient hospitalisation coverage,” said Nikhil Apte, chief product officer, Royal Sundaram General Insurance Co. Ltd. How does it work? “For example, a product of ₹5 lakh sum insured for a 30-year-old individual, OPD benefit will be ₹5,000. The premium of this plan comes out to be ₹14,224 inclusive of GST annually. Now if someone opts for basic inpatient plan then the premium will be around ₹ 5,795 inclusive of taxes with the same parameters,” said Apte. There is a huge premium difference of approximately ₹7,000 to ₹8,000 between basic inpatient plans and inpatient plans with OPD benefit.

There are also two different ways in which you get covered. “Either you get a blanket OPD cover where you get a certain amount and you can use it wherever you want or you get cashless OPD, which can only be used in a specific network of hospitals only. The cashless OPD option is comparatively a cheaper option for the insurers, which translates to lower premium,” said Chhabra.

The blanket OPD cover option is slightly more expense as you can choose any hospital. For example, Max Bupa Health Insurance Co. Ltd’s MaxBupa GoActive App has a cashless OPD option in its base plan. It has approximately 38,896 doctors in OPD network. Nothing additional is charged for the OPD cover here as it is built in the base plan. The annual premium for MaxBupa Health Insurance GoActive plan is ₹11,747 for a 30-year old male living in a metro city and a sum assured of ₹10 lakh, according to PolicyBazaar.com. On the other hand, Religare Health Insurance’s OPD rider- NCB Super premium charges you ₹3,103 for a cover of only ₹5,000, according to PolicyBazaar.com.

There are some challenges with the current status of OPD coverage in health insurance policies. “For example, if you want to go for the cheaper cashless option, you will have to go to a certain specific network of hospitals only. The OPD coverage system has not become that customer-friendly yet,” said Chhabra. The scarcity of OPD policies is caused due to the unorganised nature of the OPD value chain. “Pharmacies, diagnostic centres, clinics and appointment-booking are unorganised and do not form a connected chain. Most of the payments are done in cash and a lot of times there is no record of proper billing, which makes it a huge risk area for insurers.

Hence plans prices are higher as well,” said Rachit Chawla, founder of New Delhi-based financial advisory firm-Finway. The issue with lack of proper billing is important because it is difficult for the insurers to account for the claim in that case. “Most of the insurers give reimbursement against prescription receipts of consultation, medicines and diagnostic tests submitted to the insurer at the time of claim,” said Apte. Hence the premiums are also high.

“Sometimes an OPD cover of ₹5,000 may be charged at ₹6,000 and the coverage amount gets carried over to the next year so it gets accumulated. Even then, the premium is too high,” Chawla added.

None of the insurers have been able to crack it and create a suitable OPD cover yet. The same issues with costs and expense get spilled over to mental health’s coverage in OPD. The insurance regulator had ordered all insurers in August last year to treat mental illness at par with physical illness. So, if your policy covers OPD, you will get OPD coverage for mental health also. If your health insurance policy does not have OPD benefits, you will only be able to avail benefits on hospitalisation.

“By not having any coverage support for OPD services, quality therapy is often beyond the reach of majority of the population. When mental health concerns are not addressed, they are likely to get exacerbated, decrease the quality of life, causing emotional and often physical discomfort to the individual,” said Gitanjali Palekar, therapist and co-founder at Mind and Me Mental Health Services.

Also, claims are rejected in case of overuse of drugs or self-inflicted injuries. “HDFC Ergo rejected a mental health claim of one of the patients. The patient, a 30-year old male, was admitted because he was suicidal and his claim was rejected because of that. The insurer said this is an offence, being completely oblivious of the Mental Healthcare Act (MHA), 2017 which decriminalises suicide. They still haven’t updated their protocols,” said Mumbai-based Dr Harish Shetty, psychiatrist at Dr L H Hiranandani Hospital.

When HTMoney contacted the insurer, the HDFC Ergo spokesperson said, “According to Section 115 of the Mental Health Act, suicide has been decriminalised as defined in the Indian Penal Code. At HDFC ERGO, we are well updated with the provisions as per the Law of the Land and are in line with MHA-2017. Hence, we do not reject any claim considering suicide as an offence. Having said that, if any insured person raises a claim for treatment on account of the overuse of drugs or self-inflicted injuries, then such claims are rejected as these are part of the exclusions mentioned under a health insurance policy.”

Experts are suspicious about purchasing OPD products. “Very few companies offer OPD and that too with a lot of restrictions. So I don’t suggest purchasing such policies,” said Melvin Joseph, founder, FinVin Financial Planners. The situation does put you in a pickle because the cheaper options have a very specific network of hospitals and the ones which cover any doctor or clinic are expensive. However, if you do wish to buy one, consult your advisor.

First Published: Aug 06, 2019 11:16 IST