Do Health Insurance Policies Provide for Cashless OPD Treatment?

Purchasing a standard health insurance policy is now an almost routine budgeted expenditure for most salaried persons, especially if they are not covered by a corporate group insurance health policy. However, unfortunately, most of these standard health insurance policies only provide a cover for hospitalisation expenses. While some may even cover pre and post hospitalisation expenditure, very few cover expenditure associated with outpatient care/ day-care procedures, even though these form the bulk of a household’s medical expenditure.

Yes, it is a fact that one incurs a lot of medical expenditure that does not require hospitalisation – visits to doctors for sudden ailments or minor injuries, dental treatment or spectacles. Statistics from the Government of India’s Economic Survey 2021 reveal that India has one of the highest out-of-pocket health related expenditure in the world. Visits to the doctors and related expenditure increase if one suffers from a chronic ailment or multiple chronic ailments such as hypertension, diabetes, thyroid, etc. 

What’s more, unfortunately, most medical practitioners are unwilling to provide a diagnosis or prescription without first ordering a battery of pathological and diagnostic tests – driving the cost of Out Patient Department (OPD) treatment (or treatment not requiring hospitalisation) even higher. While some organisations do support their employees through either a lumpsum medical allowance or reimbursement of OPD expenditure either fully or partially, not all organisations do.

The good news is that health insurance policies which cover OPD or treatment costs on a cashless basis, are on track  and are beginning to gain ground. Health insurance service providers such as Bajaj Allianz, Bharti AXA, Niva Bupa and SBI allow claims against OPD treatment up to a certain limit of expenditure, or a certain limit of consultations. As a general rule, these claims can only be made in case of consultations and diagnostics undertaken at the insurance service provider’s network facilities, in which case they are likely to have the added advantage of being cashless. Additionally, bills for expenditure on medicines, etc., arising out of the covered OPD visits can also be submitted for reimbursement.

While some health insurance plans have cashless OPD cover as an integral part of the plan, not all do. Some service providers offer this facility as a supplementary or add-on plan. Recently, a health-tech start-up based in Bangalore, Clinikk has begun a totally new model that is a harbinger of hope for all those who require regular OPD services. For a nominal monthly fee of INR 500/-, Clinikk provides families with not only an INR 5 Lakh hospitalisation cover, it also provides access to unlimited and cashless OPD care. However, this cashless OPD facility can only be availed at the health centres run by Clinikk itself. Clinikk currently offers the cashless OPD facility in Bangalore and Hyderabad. Apart from OPD and hospitalisation cover, through their tech-enabled centres, Clinikk also offers those who subscribe to their policy, round the clock virtual support. Prescription medicines and diagnostic tests are also provided for under this policy.

Let us look briefly at some of the other cashless OPD plans currently available:

-    The Aditya Birla Activ Health Enhanced Platinum Plan provides cover for investigations as well as dental consultation. Available in both the individual and family floater plan, it covers visits to General Practitioners and Specialists, up to certain limits.

-    The Royal and Apex variant of the Bharti AXA Health AdvantEdge Plan covers out-patient expenses in network pharmacies, clinics and hospitals. While the total coverage offered by the plan ranges from INR 5 Lakh to INR 3 Crores, the OPD coverage has a limit of 0.5% of the sum insured and cannot exceed INR 1 Lakh.

-    The Bajaj Allianz Tax Gain Health Insurance Plan with OPD cover is a family floater plan which can be purchased by any one in the age group eighteen to seventy-five years of age. It provides a huge network of hospitals for the cashless facility. Dental treatment, spectacles and even crutches are covered under this plan.

- Digit Care Plus OPD Insurance Plan is dedicated to OPD treatment and Covid-19 hospitalisation expenses.

-     Niva Bupa has a tie-up with Practo through which it allows consultations with almost 10,000 doctors. One may avail up to 10 consultations during the policy term. Benefits depend on the premium paid.

-     Star Outpatient Care Health Insurance Plan covers treatment and consultation at any network facility.

-    SBI Arogya Plus Health Insurance Plan covers OPD costs depending on the premium, family type, and other factors such as age. It also covers hospitalisation expenses up to INR 3 Lakhs depending on the premium again.

Thus, those individuals who require frequent visits to the doctors due to chronic ailments, those with immune deficiencies, those with pre-existing conditions may find it especially useful to find a health insurance plan that covers OPD treatment costs. Keep in mind that by availing a regular health insurance cover as well as any supplementary cover you become eligible to claim tax benefits under Section 80D of the Income Tax Act.  Further, given that processing of claims is a time consuming and tedious process, the cashless OPD facility offered is all the more useful and practical for both the insured and the insurer.

It is recommended however, that one checks the fine print to see the limit to the number of visits, the limit of expenditure permissible, and whether the network hospitals where one can access treatment in order to obtain the insurance cover, are suitable to one’s requirements.