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| OPD coverage can reduce the large ticket hospitalisation claims |
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Source: https://www.businesstoday.in/personal-finance/insurance/story/opd-coverage-can-reduce-the-large-ticket-hospitalisation-claims-440477-2024-08-07 |
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| If OPD (Outpatient Department) services are allowed liberally by insurers then individuals can visit doctors (family doctor or general physician), take necessary medications, and receive treatment without the need for hospitalization. |
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| Author By S.K. Sethi, Founder & Director, RIA Insurance Brokers |
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| It is surprising that 99% of health insurance policies being sold in India do not cover OPD. The result of this is that the families or the individuals ignore the initial symptoms and when the ailment is multiplied then they end up straightway in super-specialty hospitals for treatment. |
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| Neglecting initial symptoms often leads to serious ailments. If OPD (Outpatient Department) services are allowed liberally by insurers then individuals can visit doctors (family doctor or general physician), take necessary medications, and receive treatment without the need for hospitalization. |
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| One of the suggestions which have emerged out of discussion with large number of individuals/families in different parts of India is that health insurance policies being sold in the country should have OPD coverage as one of the important point. The beginning can be done with 10% of the sum insured being available as a sublimit for OPD. For example, a policy with a sum insured of Rs. 5 Lakhs should have a sub-limit of Rs. 50,000 available for OPD treatments. |
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| This can be a good point to be taken up by General Insurance Council/GIPSA with its members and then they can discuss the matter with the Regulator IRDA, who can issue guidelines mandating health insurance companies to provide OPD coverage of 10% of the sum insured as a sublimit. Present practice of OPD as an Add-On benefit with separate payment has failed to achieve the objective. Permitting sublimit @10% would ensure that people can seek timely medical advice and treatment, potentially reducing the overall healthcare costs by preventing more serious conditions that require hospitalization. |
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| Let's take the example of diarrhea. If a person visits a general physician under OPD, the cost might be around Rs. 600 for the doctor's fee and Rs. 1,200 for medication, totaling Rs. 1,800 for the treatment. In contrast, if the same person ends up in a super-specialty hospital and is required to stay for two nights, the cost could be as high as Rs. 36,000. In this case, the insurance company would save significantly by paying Rs. 1,800 for OPD treatment instead of paying Rs. 36,000 for hospitalization, resulting in a 95% savings on hospital costs. |
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| It is also noticed that medicines being provided in super specialty hospitals are branded expensive formulations and are billed in the hospitalization invoice at full price. The same medicine in market is available in the open market @ discount of 20%. In the Jan-Aushadhi it can be available @ discount of 75% to 85%. |
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| An early diagnosis of the ailments supported with medications bought from Jan-Aushadhi outlets established by Hon’ble Prime Minister will be beneficial to the insurance industry by enabling treatment at a much lower cost. |
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| The author can be reached sksethi@riainsurance.com |
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