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Mint
4 days ago
- Business
- Mint
Should you buy OPD insurance? Get the complete lowdown to help you decide.
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 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, 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, 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.
Economic Times
19-05-2025
- Health
- Economic Times
Mental health insurance problems continue: 5 things to check before buying a cover
Getty Images All general and standalone health insurers do abide by the Mental Healthcare Act, 2017, and include mental illnesses in their health plans There has been a 30-50% rise in mental health-related claims in the past 2-3 years, claims a recent study by Policybazaar (see graphic). 'We've also seen a 41% year-on-year growth in mental health insurance searches in 2025,' says Siddharth Singhal, Head of Health Insurance, Policybazaar. The surge is corroborated by Bhaskar Nerurkar, Head, Health Administration Team, Bajaj Allianz General Insurance: 'We've seen a steady increase in mental health related claims, with a CAGR of about 33% from 2021-22 to 2024-25. In the last year alone, there was a 23% rise in such claims over the previous year.' These figures seem reassuring in the face of grim societal stigma and the fact that 10.6% of adults in India suffer from mental disorders and the lifetime prevalence of mental disorders is 13.7%, as per the National Mental Health Survey 2015-16 by Anuradha Sriram, Chief Actuarial Officer, Aditya Birla Health Insurance, strikes a discordant note. 'While awareness and conversation around mental health have increased in recent years, we have not observed a significant rise in mental health related hospitalisation claims,' she says. This is because most treatments for mental health continue to be outpatient-based, which are generally not captured in the scope of hospitalisation plans, she explains. The in-patient focus of most plans is only one of the several problems faced by people seeking mental health covers despite the insurance regulator's proactive approach in widening the scope of coverage. Though the Mental Healthcare Act, 2017, was enforced in May 2018, Irdai was forced to issue circulars in August 2018 and then again in October 2022, requesting compliance by insurers and removal of mental illnesses from their list of exclusions. The guidelines stated that mental illnesses had to be treated at par with physical illnesses when it came to providing insurers eventually started offering mental health coverage in their plans by the end of 2022, in February 2023, Irdai was again forced to issue a circular to 'mandatorily launch and immediately offer' an 'appropriate product' and a 'specific cover' for persons with mental illnesses, disabilities and HIV/AIDS, which translated to a standardised, standalone cover.A crucial inclusion was the need to put in place a 'Board-approved underwriting policy that ensures no proposal is denied'. This meant the insurers could not refuse a cover to a person with pre-existing mental all general and standalone health insurers do abide by the Mental Healthcare Act, 2017, and include mental illnesses in their health plans. 'We offer mental health coverage as part of our health insurance plans in alignment with Irdai guidelines. The plans typically cover hospitalisation expenses arising from mental illnesses, including depression, anxiety, bipolar disorder and schizophrenia,' says Priya Deshmukh, Head, Health Product, Operations & Services, ICICI Lombard. Other insurers too cover mental illnesses under their comprehensive not OPD plans: The problem with most such covers is that these are indemnity plans that only cover hospitalisation or in-patient expenses, whereas most mental disorders require periodic doctor consultations, therapies, counselling, medication and psychiatric evaluations, which are out-patient features. Policybazaar data shows that conditions like anxiety (30-35%) and depression (25-30%) are the top reasons for claims, which are usually managed through out-patient care rather than inpatient admission. Without these features and benefits, the insurance policy may not be of much use to you. 1. Does it have a pre-existing disease waiting period? If the applicant already suffers from a mental illness, buying a plan may be a challenge, depending on the severity of the disorder. In all probability, he will have to clear the waiting period for pre-existing diseases, which is 2-3 years for most insurers, before he can be covered for the disorder. 2. Does it offer OPD benefit? Doctor consultations and medication are an integral part of mental health treatments, which can only be covered by a plan with an OPD feature. So, if OPD benefit is missing, either as a part of the base cover or as an optional feature, the plan won't be of much use to you. 3. Does it cover therapy & counselling? Even if the OPD benefit is included in the plan, not all insurers offer all the features that are crucial for mental health treatments, such as therapy, counselling and psychiatric evaluations, which can be very expensive. Make sure these are a part of the cover. 4. Is your therapist or health care centre in the network? Most insurers require the treatment to be conducted by a qualified practitioner in a recognised institute, hospital or clinic that falls in its network. If these don't fulfill the insurer requirements, you will not be able to make a claim. 5. Is your illness covered? You will need to ensure that your particular mental illness is included in the plan. The disorders usually covered by insurers include anxiety, depression, bipolar disorder, schizophrenia, PTSD and dementia. If the illness is not covered, there's no point buying the cover. Agrees Sriram: 'Our flagship products are hospitalisation-focused indemnity plans, covering in-patient treatment for mental health conditions. However, many mental health treatments, like therapy or consultations, are outpatient in nature and are not covered under the base plan.''OPD coverage is crucial even as an addon because a plan that only covers hospitalisation may not suffice for real-world needs,' says Singhal. So, either the policy buyer needs to find a plan that has an in-built OPD feature, or buy an OPD rider along with the base cover, both of which require additional expense due to higher premiums that these entail. Underwriting hurdles: For people with existing mental conditions, especially with a high degree of severity, it can be difficult to buy a plan despite Irdai specifying that insurers cannot refuse it. 'While Irdai has mandated insurers to cover mental health conditions, underwriting still applies. This means that individuals with a known history of mental illness may face medical assessments, loading on premiums, or specific exclusions,' says Deshmukh. This could mean either expensive plans, limits on coverage, or long waiting periods, usually between two and three years, and sometimes even rejection for severe disorders. Network practitioners: Since the treatment for many mental illnesses requires therapy and counselling, many people pick private therapists or clinics, which may not be in the insurer networks or empanelled. Besides, correct diagnosis and effective therapy can often mean sifting through various doctors and counsellors before finding the right one that suits the patient, and not every such practitioner may be a part of the insurer network. Standardised plans: Many general and standalone health insurance companies offer a standardised plan that provides a cover of `4-5 lakh and includes mental illnesses among other disabilities and disorders. This standardised plan is an affordable base plan with similar offerings across insurers, but is available under different names and varying premiums, which is typically low. However, since it is not a comprehensive plan and offers low coverage, it means the policyholders would need to pad it up, besides buying another cover for other illnesses as well. 'Consumers should look for comprehensive plans that include mental health as part of their base coverage and evaluate whether the insurer offers any additional riders/add-ons that support out-patient care or wellness programs,' says Nerurkar. 'It's advisable to consider whether the policy offers OPD benefits for consultations, therapy sessions, and medication. Some plans also provide wellness programs or teleconsultation services, which can be highly valuable for ongoing support. Transparency regarding waiting periods, exclusions (like illnesses related to substance abuse), and pre-existing condition disclosures is critical to ensuring seamless claims later,' he should also check whether the insurer has a strong hospital network with the required facilities. 'Ensure that the insurer's network hospitals include facilities offering psychiatric services and that these are accessible in your area,' says Deshmukh.
Time of India
19-05-2025
- Health
- Time of India
Mental health insurance problems continue: 5 things to check before buying a cover
There has been a 30-50% rise in mental health-related claims in the past 2-3 years, claims a recent study by Policybazaar (see graphic). 'We've also seen a 41% year-on-year growth in mental health insurance searches in 2025,' says Siddharth Singhal, Head of Health Insurance, Policybazaar. The surge is corroborated by Bhaskar Nerurkar, Head, Health Administration Team, Bajaj Allianz General Insurance: 'We've seen a steady increase in mental health related claims, with a CAGR of about 33% from 2021-22 to 2024-25. In the last year alone, there was a 23% rise in such claims over the previous year.' These figures seem reassuring in the face of grim societal stigma and the fact that 10.6% of adults in India suffer from mental disorders and the lifetime prevalence of mental disorders is 13.7%, as per the National Mental Health Survey 2015-16 by NIMHANS. However, Anuradha Sriram, Chief Actuarial Officer, Aditya Birla Health Insurance, strikes a discordant note. 'While awareness and conversation around mental health have increased in recent years, we have not observed a significant rise in mental health related hospitalisation claims,' she says. This is because most treatments for mental health continue to be outpatient-based, which are generally not captured in the scope of hospitalisation plans, she explains. The in-patient focus of most plans is only one of the several problems faced by people seeking mental health covers despite the insurance regulator's proactive approach in widening the scope of coverage. Live Events Irdai guidelines Though the Mental Healthcare Act, 2017, was enforced in May 2018, Irdai was forced to issue circulars in August 2018 and then again in October 2022, requesting compliance by insurers and removal of mental illnesses from their list of exclusions. The guidelines stated that mental illnesses had to be treated at par with physical illnesses when it came to providing coverage. While insurers eventually started offering mental health coverage in their plans by the end of 2022, in February 2023, Irdai was again forced to issue a circular to 'mandatorily launch and immediately offer' an 'appropriate product' and a 'specific cover' for persons with mental illnesses, disabilities and HIV/AIDS, which translated to a standardised, standalone cover. A crucial inclusion was the need to put in place a 'Board-approved underwriting policy that ensures no proposal is denied'. This meant the insurers could not refuse a cover to a person with pre-existing mental disorders. Problems in getting coverage Today, all general and standalone health insurers do abide by the Mental Healthcare Act, 2017, and include mental illnesses in their health plans. 'We offer mental health coverage as part of our health insurance plans in alignment with Irdai guidelines. The plans typically cover hospitalisation expenses arising from mental illnesses, including depression, anxiety, bipolar disorder and schizophrenia,' says Priya Deshmukh, Head, Health Product, Operations & Services, ICICI Lombard. Other insurers too cover mental illnesses under their comprehensive plans. In-patient, not OPD plans: The problem with most such covers is that these are indemnity plans that only cover hospitalisation or in-patient expenses, whereas most mental disorders require periodic doctor consultations, therapies, counselling, medication and psychiatric evaluations, which are out-patient features. Policybazaar data shows that conditions like anxiety (30-35%) and depression (25-30%) are the top reasons for claims, which are usually managed through out-patient care rather than inpatient admission. 5 questions to ask before buying a mental health plan Without these features and benefits, the insurance policy may not be of much use to you. 1. Does it have a pre-existing disease waiting period? If the applicant already suffers from a mental illness, buying a plan may be a challenge, depending on the severity of the disorder. In all probability, he will have to clear the waiting period for pre-existing diseases, which is 2-3 years for most insurers, before he can be covered for the disorder. 2. Does it offer OPD benefit? Doctor consultations and medication are an integral part of mental health treatments, which can only be covered by a plan with an OPD feature. So, if OPD benefit is missing, either as a part of the base cover or as an optional feature, the plan won't be of much use to you. 3. Does it cover therapy & counselling? Even if the OPD benefit is included in the plan, not all insurers offer all the features that are crucial for mental health treatments, such as therapy, counselling and psychiatric evaluations, which can be very expensive. Make sure these are a part of the cover. 4. Is your therapist or health care centre in the network? Most insurers require the treatment to be conducted by a qualified practitioner in a recognised institute, hospital or clinic that falls in its network. If these don't fulfill the insurer requirements, you will not be able to make a claim. 5. Is your illness covered? You will need to ensure that your particular mental illness is included in the plan. The disorders usually covered by insurers include anxiety, depression, bipolar disorder, schizophrenia, PTSD and dementia. If the illness is not covered, there's no point buying the cover. Agrees Sriram: 'Our flagship products are hospitalisation-focused indemnity plans, covering in-patient treatment for mental health conditions. However, many mental health treatments, like therapy or consultations, are outpatient in nature and are not covered under the base plan.' 'OPD coverage is crucial even as an addon because a plan that only covers hospitalisation may not suffice for real-world needs,' says Singhal. So, either the policy buyer needs to find a plan that has an in-built OPD feature, or buy an OPD rider along with the base cover, both of which require additional expense due to higher premiums that these entail. Underwriting hurdles: For people with existing mental conditions, especially with a high degree of severity, it can be difficult to buy a plan despite Irdai specifying that insurers cannot refuse it. 'While Irdai has mandated insurers to cover mental health conditions, underwriting still applies. This means that individuals with a known history of mental illness may face medical assessments, loading on premiums, or specific exclusions,' says Deshmukh. This could mean either expensive plans, limits on coverage, or long waiting periods, usually between two and three years, and sometimes even rejection for severe disorders. Network practitioners: Since the treatment for many mental illnesses requires therapy and counselling, many people pick private therapists or clinics, which may not be in the insurer networks or empanelled. Besides, correct diagnosis and effective therapy can often mean sifting through various doctors and counsellors before finding the right one that suits the patient, and not every such practitioner may be a part of the insurer network. Standardised plans: Many general and standalone health insurance companies offer a standardised plan that provides a cover of `4-5 lakh and includes mental illnesses among other disabilities and disorders. This standardised plan is an affordable base plan with similar offerings across insurers, but is available under different names and varying premiums, which is typically low. However, since it is not a comprehensive plan and offers low coverage, it means the policyholders would need to pad it up, besides buying another cover for other illnesses as well. What to look for in a plan 'Consumers should look for comprehensive plans that include mental health as part of their base coverage and evaluate whether the insurer offers any additional riders/add-ons that support out-patient care or wellness programs,' says Sriram. Agrees Nerurkar. 'It's advisable to consider whether the policy offers OPD benefits for consultations, therapy sessions, and medication. Some plans also provide wellness programs or teleconsultation services, which can be highly valuable for ongoing support. Transparency regarding waiting periods, exclusions (like illnesses related to substance abuse), and pre-existing condition disclosures is critical to ensuring seamless claims later,' he says. One should also check whether the insurer has a strong hospital network with the required facilities. 'Ensure that the insurer's network hospitals include facilities offering psychiatric services and that these are accessible in your area,' says Deshmukh.
