If health insurance companies in India allowed outpatient department (OPD) services, it would mean that people could visit their family doctors or general physicians, get the medicines they need, and receive treatment without having to go to the hospital.
It’s surprising that 99% of health insurance policies sold in India do not cover OPD services. Because of this, many families and individuals ignore early symptoms of illnesses. When these problems get worse, they often end up in expensive super-specialty hospitals for treatment.
Ignoring early symptoms can lead to serious health issues. Many people believe that health insurance policies should include OPD coverage as a key feature. A good starting point could be to offer 10% of the total insured amount for OPD services. For example, if someone has a health policy with a coverage of Rs. 5 Lakhs, there should be a limit of Rs. 50,000 available for OPD treatments.
This idea can be taken up by the General Insurance Council and GIPSA to discuss with the insurance regulator, IRDA. They could set rules that require health insurance companies to provide OPD coverage of 10% of the insured amount. Currently, OPD is offered as an add-on benefit that requires extra payment, which has not been effective. Allowing a sub-limit of 10% would encourage people to seek medical advice and treatment early, potentially lowering overall healthcare costs by preventing more serious conditions that need hospitalization.
For instance, consider diarrhea. If a person visits a general physician for OPD treatment, it might cost around Rs. 600 for the doctor’s fee and Rs. 1,200 for medicines, totaling Rs. 1,800. However, if that same person ends up in a super-specialty hospital for two nights, the cost could rise to Rs. 36,000. In this scenario, the insurance company would save a lot by paying Rs. 1,800 for OPD treatment instead of Rs. 36,000 for hospitalization, resulting in a savings of about 95%.
Additionally, medicines provided in super-specialty hospitals are often expensive branded versions and are charged at full price on the hospital bill. These same medicines can usually be found at a 20% discount in local markets and at even greater discounts (75% to 85%) at Jan-Aushadhi stores set up by the Prime Minister.
By diagnosing illnesses early and using affordable medicines from Jan-Aushadhi outlets, the insurance industry can benefit from lower treatment costs.
