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OPD Coverage Health Insurance Plans
Last Updated On- 05, April 2012
(1) Who offers OPD Coverage as a part of Health Insurance Plan   (2) Policy Wording/ Proposal Form/ Brochure
(3) Product details of Various Companies for OPD Coverage Insurance Policy
General/Health Insurance Companies Products
1- 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 Pluscovers 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 Maximabenefits 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.
OPD benefit allowable under ICICI Lombard’s Health Advantage Plus:
Age of Senior Most Member Individual 2 Adults with Floater Benefit
SI under Benefit SI under Benefit SI under Benefit SI under Benefit
A= 2Lacs A= 3Lacs A= 2Lacs A= 3Lacs
  SI under Benefit B as below SI under Benefit B as below
5 yrs. - 18 yrs. 10,000 9,500 # #
19 yrs. - 35 yrs. 9,000 8,800 8,000 7,500
36 yrs. - 45 yrs. 8,500 8,000 7,000 6,500
46 yrs. - 55 yrs. 6,000 5,500 3,000 2,000
56 yrs. - 60 yrs. 4,500 3,500 # #
61 yrs. - 65 yrs. 7,000 5,500 # #
66 yrs. - 70 yrs. 4,000 2,000 # #
#-Plan not available
In Maxima OPD cover is sub-divided and the details are;
Benefits 1 Adult 2 Adults 2 Adults+Upto 2 Children
a) Total Outpatient Consultations (In Network or Non-Network*), (a = a1 + a2) 4 Consultations 6 Consultations 8 Consultations
a 1. Consultation with General Practitioner(s), Physician, Gynecologist or Pediatrician 3 Consultations 4 Consultations 6 Consultations
a 2. Consultation with other than mention in a1 1 Consultation 2 Consultations 2 Consultations
b) Diagnostic Tests with a specified Network Rs. 1,000 Rs. 1,000 Rs. 2,000
c) Pharmacy within a specified Network Rs. 2,000 Rs. 2,500 Rs. 3,000
d) Outpatient Dental Treatment within a specified Network Rs. 1,000 Rs. 1,000 Rs. 1,000
e) Spectacles, Contact Lenses within a specified Network Rs. 1,000 Rs. 1,000 Rs. 1,000
f) Annual Health Check-up within a specified Network 1 entitlement Certificate 2 entitlement Certificates 2 entitlement Certificates
The reimbursement against non-network outpatient non-network consultations is restricted upto lower of actual expenses or Rs. 350 under benefit a1 & Rs. 500 under benefit a2.
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