Difference between OPD Health Insurance Policies and Regular Health Insurance Policies

In April 2023, the Government released the National Health Accounts Estimate report. As per the report, the individual out-of-pocket expenditure (OOPE) has decreased as a percentage of total health expenditure (THE). The OOPE has decreased from 62.6% in 2014-15 to 47.1% in 2019-20. The decrease is good news and comes on the back of the Government increasing its spending on the healthcare sector and increasing penetration of health insurance. While the OOPE in India has been decreasing, it is still higher than in many other countries and has enough scope to go down further. Individuals can achieve that with a comprehensive health insurance policy that covers hospitalisation and OPD expenses. Both of these have their own importance. Let us understand the difference between them and why you should have both.

Difference between regular health insurance and OPD health insurance

The scope of coverage under regular health insurance and OPD health insurance is very different.

1) Scope of coverage under regular health insurance coverage

A regular health insurance plan covers expenses related to hospitalisation. The insured needs to be hospitalised for a minimum of 24 hours for the expenses to be covered. The exception to this is day care procedures. These treatments may require less than 24 hours of hospitalisation, and the expenses can be covered under a regular health insurance policy. The health insurance policy specifies the list of day care procedures covered under the policy.

All the other medical expenses fall outside the scope of coverage of a regular health insurance policy that provides hospitalisation cover. These expenses can be covered either under OPD health insurance, or the individual needs to pay for them from their pocket.

2) Scope of coverage under OPD insurance plans

The Out-Patient Department (OPD) of a hospital includes patients that consult a doctor without the need for getting hospitalised. After a thorough examination, the doctor advises whether hospitalisation is needed, which is not the case in most scenarios.

An OPD insurance plan may cover the following:

a) Doctor consultations

b) Diagnostic tests advised by the doctor

c) Prescription medicines

The major difference between a regular health insurance plan and an OPD insurance plan is as follows:

a) A regular health insurance plan covers hospitalisation expenses and day care treatment expenses

b) An OPD insurance plan may cover regular doctor consultations at a hospital OPD along with diagnostic tests and prescription medicines.

Why should you avail of OPD insurance plans?

You may avail of OPD insurance plans to avoid paying for the following medical expenses out of your own pocket:

a) Doctor consultations for minor illnesses like viral infections, digestive issues, body aches, accidental injuries, etc.

b) Doctor consultations for major illnesses like diabetes, hypertension, etc. These illnesses may require regular doctor consultations to monitor and keep the illness in check without the need for hospitalisation. These illnesses may require regular diagnostic tests for monitoring and ongoing medication for a long time. An OPD insurance plan can cover these expenses up to specified limits, as per policy terms and conditions.

What are the options for OPD health insurance?

An insurance company may offer OPD health insurance in the following ways:

a) In-built OPD cover as part of the regular health insurance policy

b) Optional add-on or rider with the regular health insurance policy

c) Standalone OPD health insurance policy

ManipalCigna Health Insurance Company offers the ManipalCigna Health 360 OPD Rider that provides cashless OPD coverage. The insured can select one of the 3 packages based on their needs.

The OPD rider is applicable with specified health insurance plans. The benefits can be availed on a cashless basis through the network providers of ManipalCigna Health Insurance Company. The diagnostics and medicines have to be prescribed by the Network Medical Practitioner for them to be eligible under the rider benefit. Any unutilised amount under the OPD rider cannot be carried forward to the subsequent policy year. The coverage for prescribed medicines is limited to up to 20% of the OPD rider sum assured.

How to avail of OPD cover benefits?

Insurance companies may offer OPD cover benefits through their website/app or a partner's website/app. ManipalCigna has partnered with MediBuddy App to offer OPD benefits. You can log in to the MediBuddy App, link the ManipalCigna health insurance policy with which the OPD rider is chosen, and avail of the benefits.

To book a doctor consultation:

a) Login to the MediBuddy App

b) Select “Talk to doctor” to book a consultation

c) Enter the city and pin code, and select the speciality

d) Choose the doctor’s details and date of appointment

e) Enter the beneficiary details and confirm

To book a lab test:

a) Login to the MediBuddy App

b) Select “Lab Test”

c) Enter the pin code, and select the type of test

d) Upload the prescription and confirm your details

e) Select the preferred diagnostic centre

f) Select the date of the appointment

g) Enter the beneficiary details and confirm

To order prescribed medicines:

a) Login to the MediBuddy App

b) Select “Buy Medicine”

c) Enter the pin code and upload the prescription

d) Option to choose from store pick-up and home delivery

e) Enter the beneficiary details and confirm

Buy complete health insurance for peace of mind

A regular health insurance plan can cover hospitalisation expenses. On the other hand, OPD health insurance can cover specific medical expenses that are outside the scope of a regular health insurance plan. You should consider a health insurance plan that offers OPD coverage inbuilt as part of the plan or as an add-on/rider. Having both; regular insurance and OPD coverage will cover most of your medical expenses. With such a combination, you will have little to no out-of-pocket medical expenses, giving you much-needed peace of mind.