Healthcare costs are rising.Do you need an OPD cover?

Insurers mostly offer cashless OPD coverage and reimbursements come with strict riders

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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.

But 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 or via employers.

OPD plans from insurers India's OPD market is 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 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 inal 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 cashless facility and reimbursement. 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.

Niva Bupa's Well Consult-OPD putsa co-payment of 20% for reimbursement.

Star Health Insurance has a standalone OPD cover allowing cashless and reimbursement only for accident-related emergencies.