Current scenario of OPD Insurance :
OPD Insurance covers those expenses which are incurred on an outpatient basis and do not involve Hospitalisation. They include Doctor’s consultation fees, cost of Medicines, Lab Tests, some dental treatments, etc.
According to data furnished by the Insurance Regulatory and Development Authority (IRDA), India’s out-of-pocket expense on health insurance is 62%. (Source: http://www.thehindu.com/business/out-of-pocket-spend-makes-up-62-of-health-care-costs/article21860682.ece ). Its a considerable high figure and the reason is the high Out-Patient Department (OPD) expenses.
While health insurance plans cover costs incurred for in-patient hospitalisation, coverage for OPD expenses is limited in nature. In fact, In many plans, you are forced to bear the OPD expenses yourself as they have excluded the OPD coverage.
Majority of health insurance plans do not cover OPD expenses. Some of them which do provide cover has a limited coverage. OPD expenses are either covered up to 5% to 10% of the sum insured or up to a specified absolute amount (Rs.5000 or Rs.10, 000 for instance). Moreover, there might be a waiting period applicable before coverage for OPD is allowed. The premiums are also higher for plans with OPD coverage making such plans unattractive.
Present challenges with OPD Claims:
OPD coverage is, usually, not covered in many plans or covered with less Sum assure because of the challenges it presents in ur country. Some of the challenges include the following –
- Fake claims – Making a fake insurance claim for OPD expenses is quite easy where individuals can collude with pharmacists, medical practitioners, diagnostic centres to make fake or inflated bills for OPD insurance claim. It becomes difficult for insurance companies to judge the authenticity for such claims.
- The inherent costs – OPD claims, especially those for doctor’s consultations, are of a limited amount. They might range from Rs.200 to Rs.1500. Against such small claims, the administrative costs incurred in verifying and settling the claim are high. Given the costs incurred vis-à-vis the claim amount, insurance companies are not very keen in offering OPD coverage and Individuals also find this hassled.
- Coverage vis-à-vis the premium – From the standpoint of customers, OPD coverage is not fruitful. It comes at a higher sum insured level, provides a limited amount for coverage and also includes higher premium outgoes. As such, even policyholders are not very keen on availing OPD coverage in their health insurance policies.
Cashless Settlement of OPD Claims:
The road ahead is Cashless Settlement of OPD Claims by tech solutions using Blockchain for distributed database and smart contracts which can not only create a seamless claims payments and also resolve disputes if any. There would be an environment of Trust with these automation of claims validation, assessment and payments as well as detect frauds and reduce operational costs. The objective behind cashless settlement of claims is to ensure authenticity of your claims and minimisation of fake claims.
Whatever the challenges are with OPD coverage, one cannot ignore that out-of-pocket medical expenses are considerable. The probability of hospitalisation is lower compared to the probability of incurring OPD costs. With consultation fees ranging from Rs.200 to Rs.1500 and additional thousands incurred on clinical tests and medicines, OPD expenses has become quite considerable.
From the policyholder’s standpoint, coverage for OPD has 2 distinct advantages. One, you get coverage for your minor medical costs and Two, you can claim Income Tax deduction under Section 80D on the premium paid.
While some Insurers have limited OPD coverage, others are yet to join the fray for operational issues. Lets watch out for new Healthtech solutions who can enable seamless integration of the entire OPD Claims which is the need of the hour.