Money Today: Here's why health insurance plans with outpatient cover are gaining traction

Neha Dixit, 33, is allergic to dust. Whenever she has an allergic reaction, her nasal passage swells up, giving her a runny nose, a sore throat and bouts of coughing. With her susceptibility to allergies, it is not uncommon for her to regularly consult her doctor, which is often followed by various lab tests and long medical bills. “A regular visit to a doctor costs me upwards of Rs 1,500 considering the pharmacy bills and consultation charges. I have a health insurance policy but it doesn’t cover outpatient expenses, so I end up paying a lot towards my medical bills. The family budget goes awry if other family members also fall ill at the same time,” complains Dixit.

Dixit’s case is not an aberration. Her situation is representative of the plight of millions of families, for whom out-of-pocket medical expenses constitute as high as 63 per cent of all hospital expenditure—among the highest in the world, per a 2021 NITI Aayog report. On top of that, an increase in medical inflation along with rising lifestyle diseases has only added to the burden of such families. For most of them, their health insurance policies cover only hospitalisation expenses and not outpatient expenses like doctor consultations, lab tests, pharmacy bills, etc. Hence, these expenses are met by the patients from their own pockets.

To cover this gap in health coverage, many insurers have now started offering comprehensive outpatient department (OPD) health plans. The need for having such comprehensive health plans that not only cover hospitalisation but also OPD expenses became apparent during the pandemic. That was also a time when many people were getting treated at their homes as hospitals were running full. Following the harrowing experience that patients underwent during the pandemic, demand for such policies is going up.

“Our cashless OPD numbers are growing month on month. We started April 2022 with an average of 4,400 policies per month and by the end of October 2022, the monthly run-rate had grown to 8,200 policies,” says Bhargav Dasgupta, MD and CEO of ICICI Lombard General Insurance. “We have on-boarded over 59,000 customers for cashless OPD till H1FY23 and we are getting good feedback from our partners and customers.” In addition, Dasgupta points out that the company is also selling a large number of teleconsultation-focussed sachet-size OPD propositions with group health policies.

Due to the pandemic, awareness has also grown for employee wellness programmes, with some firms now focussing on providing their employees with a health cover that not only covers hospitalisation expenses, but also other outpatient expenses. Along with that, firms are also deploying programmes that encourage employees to maintain overall good health.

The Right Choice

The OPD plans available in the market can broadly be classified into three types. “The very basic OPD plan gives you only online doctor consultations. During Covid-19, we saw a lot of them,” says Siddharth Singhal, Business Head of Health Insurance at Policybazaar.com. “Then there are plans that offer unlimited consultations with generalists or specialists—a slightly better version gives you online and physical consultations with general physicians or specialists. The most optimum plan gives you online and physical consultations and also covers your lab tests and pharmacy expenses.”

You can either buy OPD coverage as a built-in base plan, or as a rider with the basic policy. A few of the OPD policies from insurance companies include ICICI Lombard’s BeFit, Bajaj Allianz General Insurance’s ‘Health Prime’ rider, ManipalCigna Health Insurance’s ProHealth Prime Advantage, Aditya Birla Health Insurance’s (ABHI) Activ Health Platinum Enhanced and Niva Bupa Smart Health+ Acute Best Consult/Care. (See Health at a Premium for more details.)

OPD plans generally offer coverage in the range of Rs 5,000 to Rs 55,000. And how much does it cost to buy such a plan? Consider this: ICICI Lombard’s BeFit offers options ranging from only virtual consultations to both virtual and physical consultations along with pharmacy, diagnostics and physiotherapy. The premium for a 23-year-old who wants to opt only for virtual consultations is just Rs 297, with the sum insured of Rs 6,000. Similarly, for a 60-year-old person who wants the most comprehensive OPD coverage, the premium will work out to Rs 6,558 for a sum insured of Rs 55,000.

The Fine Print

OPD policies can offer wide protection—from doctor consultations, lab tests, pharmacy bills and preventive health check-ups to mental wellness and diet and nutrition counselling. But it is vital to note the exclusions, too. For instance, some cases that are not included in the plans are cosmetic treatments, hazardous and adventure sports, non-prescribed dietary supplements, treatment for addictions, spas, self-injury and STDs (sexually transmitted diseases), etc.

But a major concern with the OPD plans is the cumbersome claims process done through reimbursements. Sample this: the policy holder needs to fill out a form and submit bills and other required documents to claim the insured amount. Some of the new plans, however, do offer cashless services where one books an appointment with a doctor online, post which the claim is settled through the app.

“At ManipalCigna, all OPD claims are paid on a cashless basis. This is mainly done for two reasons: First is to reduce fraudulent claims that may arise from consultations; and second is to ensure that a customer never has to feel the pinch of paying any expense from their pockets,” says Prasun Sikdar, MD & CEO of ManipalCigna. “We have also built a strong network of hospitals so that our customers get quality healthcare.” All its claims processes for cashless OPD are app-based. A customer simply needs to book an appointment at a network hospital at a time suitable for them and visit it at that time.

Dasgupta adds that ICICI Lombard’s services, too, are cashless and delivered in a paperless manner through its in-house ‘IL TakeCare’ app. “Customers can place a request for any of the services like booking an appointment with the doctors or ordering pharmacy delivery at home or visiting labs for diagnostics, through the app,” he says.

Another key factor to examine before buying an OPD plan is that there should be enough empanelled doctors for a quick consultation. Next, you should also look at the coverage allotted for overall and per consultation OPD treatment, as it should be enough to cover consultation costs, medicines and lab tests. Moreover, it is always good to have a policy that provides the facility of OPD throughout the day.

A basic health insurance policy covers only hospitalisation costs, whereas OPD plans provide an additional layer of coverage that is especially useful in cases where a person has any pre-existing condition or lower immunity. But before buying an OPD plan, you should check the coverage, its exclusions as well as the network of doctors available in your area.

@teena_kaushal