Come July-August, seasonal illness in India usually picks up steam. The months of November to February and the current two months present seasonal challenges to the health ecosystem in India, testing hospitals, dispensaries, pharmacies and patients. But the most important player in the healthcare supply chain — health insurance — is barely involved in the cycle. This is because, most of the healthcare is dispensed on a day care basis or consultancy basis which does not involve health insurance. Even the policyholder has an ingrained notion that health insurance is only for big-ticket health care risks. This is either to protect No claim bonus or simply to avoid a lengthy reimbursement process in a short cycle service.

But Outpatient Department or OPD coverage in health insurance has improved over the years. Combined with rising impact of seasonal illnesses and wider coverage of OPD, policyholders can tackle the seasonal menace efficiently. Policybazaar has done a study on how seasonal illnesses impact health care costs in India.

Winter time diseases of Influenza or common flu and bronchitis peak in November-February and humid condition or waterborne diseases such as gastroenteritis and malaria/dengue peak in July-August. The cost of treatments has been rising in these conditions. Policybazaar reports that the average claim size in these conditions has risen by 150 per cent in the last three years.

While hospitalisation is addressed with the base policy, having an OPD cover will address mild cases.

Role of health insurance

A health insurance policy with a comprehensive OPD coverage can alleviate financial risks. As far as protecting NCB and the coverage amount is concerned, most policies may now offer multiple restorations of covers. Some policies also offer an increase in coverage amount with unused coverage of the previous year even when claimed.

Health insurance policies offer OPD coverage or e-consultations which find application in seasonal illnesses. Under a typical OPD cover, OPD consultation, along with the prescribed diagnostic tests/medicines, is covered within OPD coverage limits as part of the overall health insurance cover. Day care procedures (cataracts, orthopaedic alignments, dialysis) are different from OPD covers and may be the domain of main health insurance cover anyways.

Similarly, wellness and aesthetic consultations generally fall outside the purview of OPD cover. E-consultations or Teleconsultations are the byproduct of Covid times. This involves a virtual consultation with insurer-empanelled doctors, which can be useful as an initial examination.

OPD option in policies

Manipal Cigna’s Prime Advantage Heath Insurance offers OPD cover of ₹20,000 per policy year, which covers doctor consultations, diagnostic tests and pharmacy costs. This is a feature in the base policy itself which costs ₹11,534 per year for ₹5-lakh coverage for a 35-year-old male policyholder in the metros. There is also an option to upgrade to ₹30,000 - ₹50,000 per policy year. Tata AIG’s Medicare Premier plan also offers OPD cover of up to ₹5,000 for general treatments in the base policy, but after two years.

Several other insurers offer OPD coverage but as an optional rider. For an additional cost of ₹1,178 in Aditya Birla’s Activ Health insurance, policyholders can get unlimited cashless physical and virtual outpatient consultation by empanelled doctors, along with two references per year to specialist doctors. The base policy costs ₹9,782 for a ₹5-lakh cover.

Niva Bupa also offers unlimited tele-consultations with doctors and ₹10,000 cover amount for OPD-related consultancy and diagnostics under its rider, which costs ₹5,345 over the base policy cost of ₹8,428 for  ₹5 lakh cover.

Care’s NCB Supreme health insurance offers an 80 per cent discount on Doctor Consultation & Diagnostic Test but at the exclusive diagnostic centres and hospitals. This add-on costs ₹5,954 on a base policy of ₹11,181 for a ₹7-lakh cover.

Most of the policies mentioned also add an element of teleconsultations or e-consultation, which can be a valuable service for policyholders with limited mobility.

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