When a person needs an MRI scan which costs approximately Rs. 10,000 will it be covered by your family floater health policy? It is most probably not covered. Diagnostic tests may lead to treatment in the outpatient department (OPD) and many of these procedures which do not require hospitalization are very expensive - it would be wiser to buy a policy which covers OPD treatment.
"For an insurance company, the key is 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 hospitalization'' said Arvind Laddha, chief executive officer (CEO), Vantage Insurance Brokers.
He explained the first clause in most health insurance policies is 24-hour hospitalization. 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 hospitalization. So, technically, many of these claims could be rejected as there is no hospitalization.
General physicians and private practitioners treat OPD patients, so, 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 unorganized in India. Diagnostic tests and injections are expensive but are not reimbursed in most policies which don't cover day care tests and procedures.
"In case of hospitalization 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.
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.
Source: Priya Nair