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As your mother is covered under a family floater health insurance policy, you submit the bills to the insurer, who, however, rejects the claim as no treatment was prescribed.
Diagnostic tests like this may or may not lead to any treatment, classified under the outpatient department (OPD) or day care procedure. As many of them are quiet expensive, is it wise to buy a policy that covers OPD treatment?
"For an insurance company, the key us whether or not a line of treatment has been applied. If there is some intervention, it is likely that the claim will be reimbursed, even if there is no 24-hour hospitalisation,'' said Arvind Laddha, chief executive officer (CEO), Vantage Insurance Brokers.
He explained the first clause in most health insurance policies is 24-hour hospitalisation. Earlier, there were a lot of surgical procedures that required the patient to be admitted to the hospital. Now, many of these can be done in the OPD or in day care, and does not require hospitalisation. So, technically, many of these claims could be rejected as there is no hospitalisation.
Most insurance policies do not offer OPD coverage, as it includes doctor's consultation and leads to issues about lack of transparency and documentation.
"OPD is a wide term, not something that can be listed. It is usually anything that requires you to go to the doctor. Roughly only 50 per cent of the policies available offer OPD cover,'' aid Renuka Kanvinde, assistant vice-president, health administration team, Bajaj Allianz General Insurance.
Since OPD treatments are done by general physicians and private practitioners, documentation is poor, unlike in hospitals. Even from the point-of-view of patients, maintaining the bills and receipts can be a logistical problem. These documents are essential to ensure that your OPD claim is reimbursed.
Mansije Mishra, CEO, Max Bupa Health Insurance, agrees that the difference between OPD and day care is a grey area, since primary health care is still unorganised in India. Many a times, injections or other diagnostic tests that are expensive are not reimbursed if there is no OPD cover in the policy. Many insurers have a limited list of procedures that they cover and some don't cover them at all.
"In case of hospitalisation where there is no intervention, for instance only for observation or monitoring, we check the clinical symptoms to see how serious the patient was before deciding on the claim,'' Mishra said.
If you are looking for OPD cover, it is better to opt for a comprehensive health insurance. Usually, OPD coverage is a certain percentage of the total sum assured. You must insist on records of the medicine prescribed, bills from doctors and chemists to make the claim under OPD cover.
Also, check if the waiting period and pre-existing diseases (PED) are different for OPD and in-hospitalisation. Ideally, for OPD clams there should be no waiting period, Kanvinde said.
Keep in mind that the premium for policies with OPD is higher. For instance, in case of Bajaj Allianz's individual policy Health Guard, for a 35-year old, with a sum assured of Rs 5 lakh, the premium is Rs 6,917, while for Health Care Supreme the premium is Rs 12,402. The latter includes additional benefits like OPD, day care procedures, ambulance service and others.
Now, many corporates offer OPD benefits in the form of pre-paid cards, which can be used in specific network hospitals for specific treatment. This allows employees to get treatment at a lower rate.
