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Health Insurance with OPD Cover

Health Insurance with OPD Cover

Health insurance with OPD cover means a type of insurance policy that provides coverage for OPD. OPD health policy covers both, whether a person is hospitalized due to some illness or he visits a doctor for any illness that does not require hospitalization. Some insurance companies have special OPD plans. OPD insurance plan is the best key to full fill the nominal bills of OPD visits. Visits for minor health problems, diagnostic tests, pre-emptive check-ups and others lead one to expensive prices, especially in bigger cities. OPD coverage helps the insured to get a claim for doctor’s consultation fees, health check-ups, pharmacy bills, dental treatment, diagnostic tests and other expenses that otherwise create financial instability.

What is the OPD Cover?

OPD or Out Patient Department cover is a new feature offered as a part of the health insurance policies from insurance providers like Apollo Munich, ICICI Lombard, Bajaj Allianz and Cigna TTK. Most health insurance providers only cover for hospitalization expenses and this limits the scope of cover for Out Patient Department expenses. These expenses include doctor’s consultation fees, health check-ups, pharmacy bills, dental treatment, diagnostic tests, etc.

Features of OPD Health Insurance

  • OPD cover assists the insured to claim expenses of doctor visits and medicine also.
  • In most insurance policies with OPD cover, the insured will claim reimbursement on expenses multiple times throughout the policy amount. Out Patient Health Services embody a huge number of services and therefore a lot of transactions. This makes the cost of an insurance policy with OPD cover above that of a daily insurance policy.
  • This policy also covers pharmacy bills and thereby assists those who have more expenses from the same.
  • Regular insurance policies confirm claims after 24 hours hospitalization and the OPD cover, the sum assured is based on the age of the insured.
  • OPD expenses may be claimed at intervals ninety days of availing the insurance policy

Benefits of buying Health Insurance with OPD Cover

  • Less price as compared to inmate hospitalization.
  • Access to a wide range of clinics/doctor’s/medicines.
  • Ideal for accidental related emergencies/Ambulance-on-call.
  • Control and surveillance of communicable diseases.
  • Provides info of case history and analysis.
  • It provides a training ground for medical, para-medical, nursing workers, and future doctors.

Star Health Gain Insurance Plan

It is an offering cover for a wide range of illness, disease and injuries. A flat amount of premium has to be paid irrespective of the sum insured and the number of people covered under the plan.

Features & Benefits of Star Health Gain (Star Health Insurance):

Entry ageMinimum age: 18 months Maximum age: 65 years
Policy term1 year
Policy Type

Individual health insurance

Family floater health insurance

Family Size1A; 2A; 2A+1C; 2A+2C; 2A+3C; 1A+1C; 1A+2C; 1A+3C
Sum InsuredMinimum- Rs.1 lakh Maximum- Rs.5 lakh
Premium OptionsRs. 15,000, Rs. 20,000, Rs. 25,000 and Rs. 30,000

Room Rent – 1%

Nursing expenses – 1%

ICU Charges – Actual

Pre hospitalisation expenses – 30 days

Post hospitalisation expenses – 60 days

Day Care – All Day Care

Emergency ambulance charges – Rs. 750 per hospitalisation – Rs. 1500 per policy year

Out-Patient Benefit – Cost of Treatment as Outpatient in Network hospital

Out-Patient Benefit Limits – Will depend on Prmium, Sum Insured Choice, Family Size and Age of the Insured – Refer to OP Benefit Calculator for specific Combination

Out-Patient Benefit Limit Carry forward – OP Benefit can carried forward to next policy year on renewal. This facility is available for only one succeding year.

Key features

Coverage for both in-patient and out-patient treatment under one policy.

Pre-existing diseases are covered after 48 months of continuous insurance.

30 days waiting Period for any disease contracted by the insured – Not applicable to Hospitalisation arising out of Accident

Unutilized amount under outpatient benefit can be carried forward to the next one year


Ambulance charges for emergency transportation to hospital as per specified limits.

Tax benefits

Specific day care procedures

Tax benefitsTax benefits under section 80D of the Income Tax Act
Free look periodA free look period of 15 days from the date of receipt of the policy is available for reviewing the policy terms and conditions. In case insured is not satisfied they can seek cancellation of the policy and in such event the company will allow refund of premium after adjusting the cost of the expenses incurred at the time of availing the policy.

1.     Circumcision, Preputioplasty, Frenuloplasty, Preputial Dilatation and Removal of SMEGMA

2.     Congenital External Condition / Defects / Anomalies

3.     Convalescence, general debility, run-down condition or rest cure, Nutritional deficiency states.

4.     Psychiatric, mental and behavioral disorders.

5.     Intentional self injury

6.     Use of intoxicating substances, substances abuse, drugs / alcohol, smoking and tobacco chewing

7.     Venereal Disease and Sexually Transmitted Diseases,

8.     Injury/disease directly or indirectly caused by or arising from or attributable to war, invasion, act of foreign enemy, warlike operations (whether war be declared or not)

9.     Injury or disease directly or indirectly caused by or contributed to by nuclear


10.  A Waiting period as under-

i) First 30 days as under waiting period

ii) 24 months with continuous coverage without break (with grace period) in respect of diseases /

treatments falling under waiting period

iii) 48 months of continuous coverage without break (with grace period) in respect of Pre-Existing


iv) 48 months of continuous coverage without break (with grace period) for diseases / conditions

diagnosed / treated irrespective of whether any claim is made or not in the immediately

preceding three policy periods

Claims Procedure in Star Health Insurance:

  • Call the 24 hour help-line for assistance – 1800 425 2255 / 1800 102 4477
  • In case of planned hospitalization, inform 24 hours prior to admission in the hospital.
  • In case of emergency hospitalization information to be given within 24 hours after hospitalization.
  • Cashless facility wherever possible in network hospital
  • In non-network hospitals payment must be made up-front and then reimbursement will be affected on submission of documents.

Top Companies offering OPD (Out Patients Department) Cover:

  • Star Heath Gain Plan
  • Bajaj Allianz Tax Gain Plan
  • Apollo Munich Maxima Plan
  • Max Bupa Heartbeat Platinum Plan
  • Cigna TTK ProHealth Accumulate Plan