Who offers OPD Coverage as a part of Health Insurance in India

Who offers OPD Coverage as a part of Health Insurance in India

This is a very common question which we come across from our customers. In fact those who are familiar with USA or are returning from there find it very strange that most of the Indian insurance companies have products which do not cover OPD.

The exceptions are;
ICICI Lombard’s “Health Advantage Plus” and
Apollo Munich’s “Maxima” Health Insurance plan.

ICICI Lombard’s Health Advantage Plus covers OPD expenses from the first day of the policy. The objective of this policy is that policy holders can enjoy maximum benefit under Section 80D as per applicable tax laws. It also offers/ covers all OPD expenses i.e. consulting, tests or medicines.

In recent times, there has been a rise in the number of Caesarian section births. Increasingly we see more complicated deliveries, a series of pre-natal tests and medication which have resulted in higher childbirth expenses. Health insurance with OPD cover is thus beneficial for women during pregnancy and childbirth. ICICI Lombard provides maternity cover as part of the Health Advantage Plus policy.

The OPD cover may vary from Rs. 2,000 to Rs. 10,000 depending on the plan opted and the age profile of policy holder.

One can claim OPD charges only once during the policy term so one has to keep all the bills paid safely to get the reimbursements as and when the limit is reached.

The Apollo Munich’s Maxima benefits includes , cash- less OPD expenses across trusted network of pharmacies for pharmacy bills, diagnostic centers for diagnostic tests and annual health check-up, dental and optical care centers for contact lenses, spectacles and dental treatments along with consultation with family doctors.


The maximum benefit allowable for 1 adult is Rs. 8,500 [350*3 + 500*1 + 1,000 + 2,000 + 1,000 + 1,000 + 2,000(estimated)]

In addition, both the policies do not allow, an insured person to claim OPD cost within 90 days of commencement of the policy.

If we go for a normal health insurance policy, the premium paid is much less compared to these policies; as a result we end up paying more than the benefits we may receive.

Let us see the choice with examples:

Example 1:
Mr. X aged 30 years buys individual Health Advantage Plus plan from ICICI

Sum Insured : Rs. 3,00,000
Premium paid : Rs. 16,545
Less: Tax saved : Rs. 4,964 (30%)
Net premium : Rs. 11,581

Now if he takes normal healthcare policy from New India

Sum Insured : Rs. 3,00,000
Premium paid : Rs. 3,871
Less: Tax saved : Rs. 1,161(30%)
Net premium : Rs. 2,710

So, to avail OPD coverage of Rs. 8,800 (which he will not be able to claim without unnecessary visits etc.) he pays a premium of Rs. 8,871 extra.

Example 2:
Mr. X aged 30 years buys individual Maxima plan from Apollo:

Sum Insured : Rs. 3,00,000
Premium paid : Rs. 15,216
Less: Tax saved : Rs. 4,565 (30%)
Net premium : Rs. 10,651

Now if he takes normal healthcare policy from New India:

Sum Insured : Rs. 3,00,000
Premium paid : Rs. 3,871
Less: Tax saved : Rs. 1,161 (30%)
Net premium : Rs. 2,710

So, to avail OPD coverage of Rs. 8,500 (which he will not be able to claim without unnecessary visits etc.) he pays a premium of Rs. 7,941 extra.

The conclusion drawn is by having these policies you are getting the benefit in the ratio of 1:1 only.

Should health insurance be made compulsory?

The infant mortality rate in India is 10 times that in UK; it is also far higher than whole host of other developing countries (four times that of Sri Lanka, for example). A vast majority of deaths are preventable even with our present level of income. Other key health indicators, particularly maternal mortality and nutrition are equally distressing. Amongst children below five in India, 46% are under-nourished, 36% stunted and 22% wasted. Imagine the impact on each affected family, the depth of the unnecessary human tragedy, beyond the cold statistics.

The magnitude of health crisis has not got the recognition it deserves. Civil society organizations too have not been able to mobilize widespread public awareness. Many people feel that there is a need of an action plan on healthcare.

Government has been looking for alternatives, and people will like to go for ggod facilities even though they cannot afford the cost. For the poor, sickness is not just a matter of physical ill-being but also has a deep and long-lasting economic impact and productivity loss to the nation. It also affects GDP of the country.

Indian model of healthcare has largely been a private-insurance based one and as costs of healthcare will increase so the insurance premium will also increase whether we like it or not.

While the insurance industry is capitalizing on unmet demand and we also have large number of patients through conventional healthcare facilities, there is also a huge potential for technological solutions.

The government needs to leverage the new possibilities and integrate them into a comprehensive healthcare system, rather than stepping back and leaving things only to market forces.

In the recent years the government has done a wonderful job by bringing in RSBY for the benefit of poor people ,who till recently could not afford health insurance policies on their own.

Senior citizens have been complaining about non availability of health insurance of right amount and against payable of right or we can say reasonable premium.We feel now the time has come and Health Insurance should be made compulsory at least for the senior citizens.The positive impact of this will be that this will give a good boost to the insurance industry.

The idea is from the date of start 18 months will be given for all those who are 60 + yeras to get the policy issued. Wide publicity will be given thro various media to popularize this concept. Assume Rs 2000 per person per year is given as subsidy for first 2 years.

Let us assume 200 Lakhs senior citizens avail the offer and Rs 6000 is the premium then Indian insurance industry will get additional revenue of Rs. 12,000 crores. The insured senior citizens will pay Rs 4000 while the balance Rs 2000 will be paid by the governement.

The present figure of Rs 6600 crores will be going up by Rs 12000 crores and this will take the Health Insurance Industry to new heights .We are sure the portfolio will become profitable as at present only those who are expecting to lodge claims buy insurance. This will give boost to GDP, health care infrastructure and employment to large number of doctors/nurses .technicians, IT personnel.

Let us try to push this idea and improve the health of our health insurance industry. Your comments will be appreciated.

Need for health insurance policy for millions of bed-ridden senior citizens of India

Like in any other country there are many senior citizens in India who are bed-ridden and dependent on others. Their number is increasing year by year and is going to touch very large numbers by 2025.

Recently a sample of 1,000 bed-ridden senior citizens were surveyed, 600 were from Delhi and 400 from its satellite townships.

It has been found that 4% of the 2.5 million elderly in Delhi/ NCR are bed-ridden and require round-the-clock care. At any given point of time, almost 5% to 6% senior citizens live with the threat of ailments, which may render them bed-ridden.

Approximately 65% of the bed-ridden patients were reported from among the elderly person’s category and these patients face many problems, including non-availability of care-givers, depression and nervousness, lack of cleanliness & hygiene, bedsores and high blood pressure.

It was also found that 86.1% of 1,000 reviewed were affected by physical chronic illness, heart attacks or accidents while 13.9% were suffering from different kinds of mental and psychological problems.

31% bed-ridden patients reported that they needed care-givers urgently or were without any proper care-giver. 38% patients were being taken care of by their spouses, 23% by their family members and 39% by care-givers.

There were more bed-ridden men than women – 67.5% against 32.5%. 66.5% of the patients were confined to bed for a short period (less than 12 months) while 33.5% were long-term patients. 76.5% were partially affected while 23.55 were severely affected.

There is a need for training family members to take care of the bed-ridden patients and help them accept their condition. It is imperative to initiate training programme for affected family members and relatives of bed-ridden patients so that hey can get adequate knowledge and information on how to tale care of persons confined to bed.

The question before us is that these bed ridden patients are not covered by health insurance policy because they are suffering while being at home and they are not in hospital.

We will welcome an innovative product from at least one Insurance company which will take care of such patients –many of them being patient of depression, which is not covered at present.