Difference Between Regular Health Insurance Plan and OPD Health Insurance Plan

The government of India released the report of National Health Accounts Estimates (NHAE) in April 2023. The report

states that the out-of-pocket expenditure or OOPE of individuals has decreased from the Total Health Expenditure (THE) percentage. The OOPE was 62.6% during 2014-15. However, in 2019-20, it was estimated to be 47.1%. The decrease in OOPE is good news for a developing nation. It indicates a good sign of the government increasing the healthcare infrastructure and insurance penetration in the insurance sector. Nevertheless, it is important to note that the OOPE is still higher as compared to other developed nations. It still has the scope to move downward. India may achieve this goal with a comprehensive health insurance policy. It covers both hospitalisation and OPD costs. Both coverages have their own importance. Hence, it is crucial to understand the meaning and difference between regular and OPD health insurance policies.

Difference Between Regular Health Insurance and OPD Health Insurance Policy

The coverages provided by regular health insurance and OPD health insurance are different.

Coverage Under Regular Health Insurance Policy

The regular health insurance plan offers coverage of expenses pertaining to the hospitalisation of a policyholder. The policyholder is required to be hospitalised for a minimum period of 2 hours in order to cover the expenses incurred by the insurance company. Day care procedure is the exception to regular health insurance policy. These treatments do not require more than 24 hours of hospitalisation. Such treatments can be accomplished in less than a day. The expenses under the day care procedure shall be covered by the regular health insurance policy. The insurance policy mentions the list of day care procedures which are expected to be covered under the regular health insurance policy.

However, the other medical expenses shall fall outside the purview of the regular health insurance policy. These expenses can only be covered by the OPD health insurance plan. In the absence of an OPD plan, the policyholder is required to pay the medical bill from his own pocket.

Coverage Under OPD Insurance Plans

The patient is not required to be hospitalised in order to fall under the purview of OPD coverage. The patient generally obtains consultation from the doctor regarding health issues.Under this, the patients are not expected to be hospitalised. Hence, the coverage is offered under the scope of the OPD insurance plan.

The OPD health insurance plan includes the following coverage.

• Doctor Consultation: The patient visits the clinic of the doctor and states the health issues he confronts. The doctor advises the patient to do or not to do certain acts in order to avoid such a health issue.
• Diagnostic Tests: In this case, the doctor advises the patient to obtain certain tests in order to better comprehend the cause of the health issue.
• Prescription Medicines: Upon testing the patient, the doctor prescribes certain medicines to be consumed by the former in order to evade the health issue he faces.

Now, one may draw the major differences between the regular health insurance plan and the OPD health insurance plan.

• A regular health insurance plan offers hospitalisation expenses along with the cost of day care treatment.
• The OPD health insurance plan covers the costs incurred by the policyholder in doctor consultations, diagnostic tests and prescription medicines.

Why Should an Individual Subscribe to an OPD Insurance Plan?

An individual or policy buyer must purchase an OPD insurance plan in order to avoid the following expenses.

• The policyholder may avoid doctor consultation fees for minor illnesses. This includes digestive issues, accidental injuries, viral infection, body aches etc.
• Doctor consultations also include major illnesses which may be evaded by purchasing an OPD insurance plan. Such major illnesses include hypertension, diabetes, etc. Such illness may require a doctor to monitor the development and seriousness of the disease. However, it may also be accomplished without any hospitalization. Therefore, an individual must purchase the OPD insurance policy to obtain the aforementioned coverage. It is important to note that the OPD expenses are covered to a specified limit. It shall be treated according to the terms and conditions of the insurance policy.

Benefits of Insurance Plan

The regular health insurance plan and OPD health insurance plan come with several benefits.

Benefits of a Regular Health Insurance Plan

Here are the key benefits of a regular health insurance plan.

• Hospitalization Expenses: The regular health insurance plan covers the hospitalization expenses of the policyholder. Every medical treatment cost which may be incurred during the hospitalization shall be covered by the regular health insurance plan. It covers the cost of doctor’s fees, nursing charges, and medicines cost. In addition, it also covers the additional expenses. This includes the ICU charges, room rent, diagnostic tests, etc.
• Pre-Hospitalization and Post-Hospitalization Expenses: The regular health insurance plan covers the pre-Hospitalization and post-hospitalization expenses of the insured. Every medical expense incurred by the policyholder from 30-60 days before the hospitalization shall be covered by the regular health insurance plan. In addition, the policyholder shall also be entitled to the medical expenses incurred during the hospitalization or recovery stage. On top of that, the insurance company shall also provide coverage for 60-90 days post-hospitalization. However, the duration mentioned above may differ or vary from insurer to insurer.
• Day Care Procedure: As mentioned earlier, some treatments may require the policyholder to be hospitalised for less than a day or 24 hours. The regular health insurance policy offers coverage for the expenses incurred from the day care procedure. It is advised to the policyholder to check the list of the day care procedures which are covered under the regular health insurance policy.
• Domiciliary Treatments: There might be a case when the health condition of the insured may not permit him to move to the hospital in order to obtain the treatment. In addition, there may also be a time when the hospital can run out of beds. Under such circumstances, the doctor recommends the policyholder obtain the appropriate treatment at home. The hospital shall provide a doctor and trained supervision to the policyholder.

Benefits of the OPD Health Insurance Plan

Here are the key benefits of the OPD health insurance plan.

• Medical Expenses: The OPD health insurance plan offers the medical expenses incurred by the policyholder without being hospitalised. It is important to note that in case of hospitalisation, the OPD health insurance plan shall not cover the insured. It may only cover the insured for the treatment which does not require any hospitalisation.
• Fees of Doctors: The OPD health insurance plan offers coverage which includes pharmacy bills, diagnostics charges, consultation fees of doctors, etc.
• Regular OPD Visits: The OPD insurance plan is a beneficial product for the policyholder who needs regular OPD visits.
• Income Tax Deduction: The premium paid by the policyholder shall be deductible from the taxable income.
• Reduces Financial Burden: The OPD insurance plan is an ideal product for policyholders with pre-existing or chronic conditions.

Conclusion

A regular health insurance plan offers hospitalisation expenses. At the same time, the OPD health insurance plan covers specific medical expenses. The policyholder is not required to be hospitalised in an OPD health insurance plan. The treatment can be done by paying a visit to the medical practitioner. The OPD health insurance product covers the expenses incurred by the policyholder to pay the doctor fees. This includes pharmacy bills, diagnostics charges, consultation fees of doctors, etc. It also covers the charges paid by the policyholder for the regular visit to the doctor. Hence, it is an ideal plan to reduce the financial burden and claim an income tax deduction.

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FAQs

Q. What are the exclusions of OPD insurance coverage?

A. Here are some exclusions of the OPD insurance cover.

• A treatment which is availed for beautification or purification shall not be covered.
• The insurer shall not offer any coverage for the OPD treatment outside India.
• The cost borne by the policyholder to purchase implants, lenses, and spectacles shall not include in the OPD insurance cover.

Q. What are the expenses which may be covered under the OPD health insurance?

A. The below-mentioned expenses can be covered under the OPD health insurance.

• Pharmacy Expenses: Expenses incurred by the policyholder to buy medicines shall be covered by the insurance company.
• Doctor Consultation: It shall also be covered by the insurer.

Q. What is the process of claim settlement of OPD cover?

A. The policyholder is required to provide the hospital bills and other documents sought by the insurance company in order to settle the claim.

Q. Can an individual buy a health insurance policy which solely covers OPD treatment?

A. It is at the discretion of the insurance company whether it provides the insurance policy which only covers OPD treatment. Therefore, the policyholder must review the plan carefully in order to find out the insurance companies which cover the OPD treatment.