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Health Insurance Policies Which Cover out-Patient (OPD) Benefit


Summary

Cover out Patient Benefit

1. Aditya Birla – Activ Health Platinum Enriched Insurance Plan:

i) Coverage: The policy will cover the costs incurred for medically necessary consultations, diagnostic tests, and pharmacy expenses on an outpatient basis up to the amount specified under the policy. The appointments can be scheduled through the website or through the mobile application or call the toll-free number to schedule the appointments.

  • The expenses incurred on outpatient consultations by a general medical practitioner or specialist medical practitioner. A maximum of 10% of the sum insured would be covered for every consultation. 
  • Outpatient diagnostic tests or medicines purchased from the pharmacy as prescribed by the medical practitioner would be covered up to a maximum of 50% of the limit specified under the policy schedule for OPD expenses.
  • Outpatient diagnostic procedures in case of a road traffic accident as prescribed by the medical practitioner up to a maximum of ₹ 10,000 over and above the OPD limit as mentioned in the policy.
  • These services can be availed at the network hospitals on a cashless basis. If these services are available at a non-network hospital then the insured can go on a reimbursement basis.
  • If the insured has not utilized the sum insured completely under the policy then the unutilized sum insured would be carried forward to the next policy year, and should be utilized within 12 months after carried forward to the next year.

ii) OPD Bonus on Unutilized OPD Expenses: The insurance company will add an OPD Bonus of 5% to the unutilized OPD expenses at the end of the policy period, provided that:-

  • The OPD bonus would apply even if claims are made under other benefits of the policy
  • OPD bonus would be calculated on the unutilized OPD expenses
  • The OPD bonus will not apply if the policy is not renewed within the grace period
  • The OPD bonus is not applicable on the unutilized limit for road accident diagnostic.

iii) Conditions: The OPD benefits shall be available on an individual basis to each eligible insured person up to the limit specified in the policy for an individual policy as well as a floater policy. The limit for OPD expenses under this policy for each insured person shall remain the same in case of a family floater policy.

ReadWhat are the Benefits of Super Top Up Health Insurance Plan?

2. Bajaj Allianz Tax Gain:

i) Coverage: The policy will cover the outpatient medical expenses in case of treatment required on an outpatient basis on the advice of any medical practitioner because of illness or accidental bodily injury during the policy period.

The policy will pay the reasonable and customary outpatient expenses incurred by the insured, subject to the maximum limit of indemnity as mentioned in the policy.

ii) Waiting period: There are certain waiting periods under the policy which are mentioned below:

  • Cost of spectacles is not paid in the first year of the policy. The cost of spectacles is paid in the second year of continuous renewal subject to a maximum of 25% of the OPD limit.
  • Cost of dentures in the first 2 years. The cost is paid in the third year of continuous renewal subject to a maximum of 25% of the OPD limit.
  • Cost of hearing aids in the first 2 years of the policy. The cost is paid in the third year of continuous renewal subject to a maximum of 25% of the OPD limit.

iii) Specific Exclusion:

  • Any expenses for treatment which is taken without a doctor’s prescription or advice
  • Any expenses for diagnosis tests without the treating doctor’s referral
  • Cost of annual health checkup
  • Any expenses in excess of the maximum payable under the outpatient medical expenses limit.

3. Star Outpatient Care Insurance Policy:

i) Eligibility: Minimum Entry age- 18 years Maximum Entry age- 50 years.

ii) Family size: Up to 6 members, dependent children will be covered if any one of the parents are covered under the policy.

iii) Sum insured options: Rs. 25,000 to Rs.1,00,000

iv) Coverage:

  • Outpatient consultation expenses are incurred at any network facility in India.
  • Nonallopathic treatment expenses, such as those incurred on Ayurveda, Yoga, Unani, Siddha, and Homeopathy, may be claimed by any institute recognized by the Government of India and or accredited by the Quality Council of India or the National Accreditation Board on Health.
  • Expenses incurred for diagnosis, physiotherapy, and pharmacy at any of the network facilities in India for treatment as an outpatient.
  • Dental treatment expenses to a natural tooth or teeth arising out of accidents at any of the network facilities in India as an outpatient.
  • Ophthalmic treatment expenses arising out of accidents incurred at any network hospital in India as an outpatient.

4. Niva Bupa Go Activ Health Insurance Plan:

i) Coverage: The OPD consultation taken during the policy period will be covered subject to:

  • The maximum number of consultations is specified in the policy schedule. The maximum number of OPD consultations under the policy is 10 depending on the number of members in the policy and the sum insured mentioned under the policy.
  • OPD consultation can be availed either through a Cashless Health Insurance Claim Facility facility or on a reimbursement basis through a network hospital. In case of reimbursement, the maximum per consultation limit is ₹.600 for Zone 1 and Rs. 500 for Zone 2 coverage.
  • OPD consultation shall be requested through the mobile application or website
  • The number of consultations will be applicable for all the insured persons on a cumulative basis for the policy year.
  • Any unutilized consultations cannot be carried forward to the next policy year.
  • There is no co-payment for the OPD expenses incurred under the policy.
  • There is no refill benefit available to the insured under the OPD expenses cover.
  • There are no waiting periods that are applicable under the policy.
  • In case of reimbursement, the maximum amount would be the amount per consultation as mentioned in the policy.
  • Reimbursement for OPD consultation shall be submitted within 30 days from the end of the policy year.
  • Treatment normally taken on an OPD basis cannot be included in the daycare treatment.

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Susheel Agarwal

Namaste. I'm Abhinay Nedunuru, a Fellow of the Insurance Institute of India with a passion to make insurance simple and crisp. I write mostly on insurance and investment. I have a passion for teaching and training in particular to insurance. I'm currently doing my PhD from IIM in Marketing Management.