Should you buy OPD insurance? Get the complete lowdown to help you decide.

Mint

3 days ago

Imagine this: you have some health issues and visit a doctor. She prescribes you medicines and a couple of diagnostic tests. You pay a good amount of money for the doctor's consultation, medicines and tests, and wonder whether your health insurance policy will cover it.
Well, here's the bad news: most health insurance policies do not cover outpatient department (OPD) expenses. According to a report by India Insurtech Association, India's OPD spending amounted to a massive $37.7 billion in FY24, of which retail OPD insurance accounted for less than 0.1%.
Noting this gap, insurers have of late started to offer OPD coverage and healthcare startups have also entered the space, providing OPD subscription plans directly to customers or via employers.
Here's a lowdown of what all is available.
OPD plans from insurers
India's OPD market is highly fragmented, so providing coverage is difficult. The high chances of billing fraud can't be ignored, so insurers prefer to offer OPD coverage on a cashless basis, allowing you to only visit their network partners for doctor consultations and diagnostics.
Some insurers may agree to reimburse the cost incurred at non-network facilities as well. Among popular plans, as shared by Policybazaar.com, ICICI Lombard's Elevate comes with an OPD+ rider. The premium varies by age. A 35-year-old male must pay ₹4,980 annually for ₹10,000 OPD coverage in a year. The plan only works on a cashless model and has no sub-limits on procedures such as dental and vision.
Bajaj Allianz's Health Prime and Niva Bupa's Acute-Best Care offer both cashless facilities and reimbursements. The former has a premium of 2,062 for ₹15,000 coverage while latter costs ₹4,801 for ₹10,000 coverage for a 35-year old individual.
Niva Bupa's Well Consult-OPD puts a co-payment of 20% if a policyholder files for reimbursement. Star Health Insurance has a standalone OPD insurance policy that allows cashless and reimbursement only for accident-related emergencies. A 35-year old individual will pay ₹4,802 for ₹25,000 coverage. This plan has a waiting period of 1-3 years for OPD expenses of pre-existing diseases.
"Traditionally the OPD plans had sub-limits on doctor consultation, diagnostic tests or pharmacy bills. For example, the OPD sum insured could very well be ₹20,000 but pharmacy bills having a sub-limit of ₹5,000. But insurers are increasingly launching plans with no sub-limits for customers to utilise the OPD benefit in the way they want," said Siddharth Singhal, business head - health insurance, Policybazaar.com.
Direct-to-consumer plans
Lucknow-based Geeta Srivastava (66) heard about healthcare startup LivLong's OPD plan Eldercare. "The plan costs me ₹12,000 a year. OPD benefits such as medicines and lab tests are restricted to ₹3,000 a year, but there are other useful benefits such as full-body check-up (83 parameters), unlimited consultation with doctors and nutritionists, six consultations a year with specialists and two free ambulance services. Another benefit is having a healthcare manager at my disposal who checks up on me every now and then and helps me with what I require," Srivastava said.
Data from LivLong showed they have three plans, priced at ₹5500, ₹6,000 and ₹11,599. "These plans have a perceived value of ₹15,000, ₹16,000 and ₹28,800, respectively," said Gaurav Dubey, founder & CEO, LivLong 365.
To be sure, there is no underlying sum insured in LivLong OPD plans. They offer up to 50% discounts on OPD benefits such as consultations, lab tests, diagnostics and medicines, which translate into perceived savings.
Healthcare provider Even Health offers OPD insurance in partnership with Magma General Insurance. However, you can't buy standalone OPD cover from them. You need to buy IPD cover (sum insured ranges from ₹3 lakh to ₹1 crore) in which OPD cover of ₹10 lakh will be inlcuded if you pay extra over the premium. People aged 0-35 years can buy it for around 4,500 a year, 36-49 years for ₹10,000 a year, and over 50 for ₹19,000 a year, excluding the premium for IPD coverage.
"Our OPD plan works everywhere in the country on a cashless basis. We have partners in every pin code from Lakshadweep to Leh. We not only cover doctor's consultations but also diagnostic (radiology, pathology) and medicines. We offer reimbursement, too, but with 50% co-pay," said Mayank Banerjee, Co founder, Even.in.
Coverage from your employer
Companies such as Onsurity and Plum, or for that matter even Even Health and LivLong, curate OPD coverage in partnership with employers to offer it to employees.
Noida-based Anmol Bhushan (28) works with a financial services firm as an actuarial consultant. His employer offers OPD benefits as part of its wellness services. He pays ₹11,000 per year to insure himself and his parents for a maximum benefit of ₹21,000. "The plan has a co-payment of 10% for me and 20% for my parents. Each year I manage to avail of at least ₹18,000 benefit," said Bhushan.
Data from Onsurity shows their wellness OPD plans cost a minimum of ₹145 more per member per month and can go up to ₹4,500 or more based on the features. "Pricing retail OPD plans at a low cost is difficult because the utilisation will be high in those plans. We offer it to them via employers so that the utilisation is comparatively lower and we can keep the pricing viable," said Suman Pal, chief claims officer at Onsurity.
Can't argue with free
Some employers offer the benefit to employees for free. Mumbai-based Dipen Chheda (50) for example, used it while he was working with his previous employer. "The challenge in that plan was the limited number of associated partners. If I have to take doctor consultation and no network doctor is available nearby, it does not make sense for me to go far. Similarly, nearby chemists also offer discounts on medicines. Sometimes those are better than what OPD cover offers," he said.
For Bengaluru-based Shobhit Katikia (27), the experience has been great. "We get a flat coverage of ₹20,000 per year from our employer. I don't have to pay for it. It covers me and my parents. I availed the claim twice in the past two years – for dental treatment that included the procedure and medicines in the first year, and for new glasses in the second year. The cost of the eye check-up, frame and lens was all covered," he said. In his case, he could choose any doctor or pharmacy and file for reimbursement. "The claims were approved in 24 hours," he said.
Should you buy an OPD plan?
Well, it depends on the cashless network the platform provides, and the sub-limits. "We have noticed that doctors empaneled with different such platforms may just have an MBBS degree and not really be specialists. The way the OPD market works is people may want to visit specialists and diagnostic centres of their choice. We are in the process of launching retail OPD cover, which will address these issues," said Saurabh Vijayvergia. founder & CEO, CoverSure.
Mint's take
India's OPD insurance market is at a nascent stage. While employer-linked OPD cover offers decent benefits, there are very few direct-to-customer options from healthcare startups. There is greater variety in policies offered by insurers. Whichever option you choose, sub-limits on various benefits make such plans restrictive. You could considering buying it to giving it a try if you can afford it.