OPD vs IPD Coverage in Health Insurance: Understanding the Key Differences

8 min read Posted on 30 Aug 2024

Health insurance is a must-have asset for individuals who want to stay financially protected against medical emergencies. COVID-19 was a wake-up call, and the demand for health insurance in India has shot up by 321% (Source). Are you protected with one? Health insurance companies offer various features in a hhealth insurance plan that maximize medical protection for policyholders.

You may consider different benefits, including network hospitals, individual or family floater plan types, surgery expenses, etc. OPD and IPD coverage are another crucial features that your health insurance should provide.

But are you aware of OPD and IPD coverage and its unique benefits in healthcare? This article discusses OPD and IPD in detail, including the key differences and exploring how to leverage them to your healthcare advantage.

What is OPD Treatment?

OPD Full Form: Out Patient Department

OPD care is a medical facility within a hospital or a healthcare centre that covers the expenses of medical consultations, diagnosis, and treatment, where the patient's admission is not required. The doctor assesses the patient's condition, conducts the required diagnostic test, and consults for various treatments or medications without admitting the patient to the hospital. OPD care is generally conducted on a daycare basis.

What is Covered Under OPD Treatment in Hospital?

OPD treatment in your health insurance covers short-term visits to the doctor for regular health check-ups and treatments. The following are the advantages and coverage under OPD:

Doctor Consultation Fee: Covers the charges for visits to a physician or specialist for consultation.

Preventive Health Check-Ups: Schedule appointments for your regular health check-ups and diagnostic tests and get coverage. This makes it easy for the insured to be aware of diseases and take action on time. These also include pregnancy check-ups and paediatric treatments.

Minor Illnesses Covered: OPD treatment is the best way to get medical care for minor illnesses, injuries, and medical procedures that do not require hospitalization.

Follow-Ups: The post-surgical follow-ups after the medication, in case of chronic medical conditions like Diabetes, PCOS, infections, etc., are also covered.

How Can I Make an OPD Claim?

Generally, outpatient claims are reimbursement claims to retain all the bills after receiving the treatment. Below is the OPD claim resolution process that you can follow:

Receive the Consultation or Treatment: The patient undergoes the treatment, consultation, required diagnostic tests, or minor procedures as prescribed by the doctor.

Keep the Records: After paying the bills for the required procedures and medications, keep all the records safely, including bills, pharmacy expenses, invoices, prescriptions, and receipts.

Submit Claim: The insured should download or collect the claim form from the health insurer and submit it to the company with all the supporting documents. The insurer may require you to submit additional documents.

Evaluation of the Claim: The health insurance company reviews your claim form and verifies the supporting documents. They then evaluate the claim's eligibility per the policy's terms and conditions.

Claim Processing: Once your claim is approved, the health insurer will process the eligible reimbursement based on the policy coverage. The reimbursement is then transferred to your account or the hospital.

What is IPD Treatment?

IPD Full Form: Inpatient Department

The IPD is a medical facility where the patient needs to stay overnight for at least 24 hours or longer in a hospital or a healthcare centre. IPD care is required when the patient requires admission to treat severe medical conditions, diseases, or illnesses. During the IPD treatment, the doctor continuously monitors the patient and provides critical care.

What is Covered Under IPD Treatment in Hospital?

Major surgeries and complex medical procedures require inpatient care and hospitalization. Below are the coverages an insured can benefit from under IPD insurance coverage:

Hospitalization Costs: When the patient is hospitalized, IPD includes treatment costs, room charges, nursing expenses, diagnostic test charges, surgical interventions, operation theatre charges, surgeon fees, etc.

Intensive Medical Care: IPD treatment provides intensive care to the insured who require continuous treatment and monitoring for treating complex medical conditions. Their progress is assessed, and immediate care is provided for complications.

Pre and Post-hospitalization Expenses: Some IPD insurance under a health insurance plan covers pre and post-hospitalization expenses within a specific period.

Prescriptions and Medications: Depending on the policy terms and conditions, IPD insurance covers the cost of medicines and drugs prescribed during the hospital stay.

Post-Operative Care and Recovery: IPD covers the expenses incurred during post-operative recovery. Healthcare professionals closely monitor progress to ensure a steady and healthy recovery.

Important Read: Buy affordable cashless health insurance plans

What is the Process for IPD Claim Resolution?

Generally, two types of claims are raised under IPD treatment: cashless claims and reimbursement claims. Follow the below step-by-step guide to proceed with the IPD claim resolution.

Cashless Claim

Cashless claims are raised when the insured undergoes treatment at the network hospital. The insured can apply for an IPD cashless claim by following the given steps:

Receive the Treatment: After consulting with the doctor, get admitted to a network hospital for inpatient treatment. Notify the insurance company or the third-party administrator (TPA) before the hospitalization.

Pre-Authorization Process: The insurer then sends the authorization letter to the hospital outlining the specific coverage and upper limit.

Keep the Records: During your hospitalization, undergo treatment. Keep all the records, including hospital bills, reports, invoices, medical reports, discharge summaries, etc.

Initiate Claim: Fill out the claim settlement form and submit it with the required documents.

Review of Claim: The insurance company or the TPA verifies the claim for the applicable coverage.

Claim Processing: Once the claim is approved, the health insurer directly settles eligible claims with the network hospital. You will have to pay out of your pocket for expenses not covered under the policy.

Reimbursement Claim

The IPD reimbursement claims are raised when the insured undergoes the treatment at a non-network hospital or when the cashless claim facility is unavailable. In such instances, the insured needs to pay the bills from their pockets up front. Later, the claim is reimbursed by following the given steps:

Discharge From the Hospital: After receiving the required treatment, complete the discharge formalities and collect all the essential documents regarding the treatment summary.

Submit the Claim: Download and submit the duly filled claim form with the required documents to the health insurance company or TPA within the specified time limit as in the policy.

Claim Review: The health insurance company verifies the claim and assesses whether it complies with the terms and conditions of the policy.

Claim Processing: Depending on the policy coverage, the company reimburses the eligible expenses to the insured through a bank transfer or cheque.

OPD vs IPD: What’s the Difference?

Look at the difference between the OPD and IPD treatments in detail.

Basis	Outpatient Department (OPD)	Inpatient Department (IPD)
Definition	The department offers healthcare services to patients for short visits (who do not require admission to the hospital)	The department provides comprehensive medical care to the patients who are required admission to the hospital for a certain period
Coverage Offered	Doctor consultation, diagnostic tests, minor care and procedures, vaccinations, medication, preventive care	Surgery, intensive care, continuous monitoring, rehabilitation, hospitalization expenses, complex medical treatments,
Duration of Stay	Short duration visits	Admission ranges from a day to several weeks
Location	Conducted in outpatient clinic or doctor's office	Conducted within the hospital or healthcare facility
Cost	Comparatively low	Higher due to hospitalization and accommodation costs
Claim Process	Reimbursement claim	Cashless and reimbursement claim
Service Example	Regular check-ups with specialist Dental check-up Blood test X-rays Vaccination	Cataract surgery Knee replacement surgery Major surgery Organ transplant Complex medical conditions
Coverage Limitations	A limited number of visits allowed Defined reimbursement amount for different services	Based on the sum insured Sub-limit for defined expenses Comprehensive coverage
Access to Care	Appointment required	Hospital admission
Nature of Treatment	Routine or non-urgent check-ups	Critical (emergency and non-emergency) medical intervention
Treatment Intensity	Less intensive medical intervention	Extensive and specialized treatment
Waiting Period	No waiting period	May have a waiting period excluding the cases of group health insurance

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What Factors Should I Consider While Choosing Between IPD and OPD Coverage?

Selecting IPD and OPD coverage in health insurance completely depends on your and your family's health requirements. Below are the factors that you can consider while choosing between IPD and OPD coverage with your health insurance plan:

Healthcare Requirements: Determine the current and future healthcare needs of your and your family. Minor health conditions that require health check-ups and consultations are preferred, as well as OPD coverage. If you or any of the family members has/ have severe illness or disease, leading to a high risk of needing admission to the hospital, IPD coverage is the better fit.

Budget: Decide how much you are willing to spend on health insurance. OPD coverage is comparatively cheaper than IPD coverage. Do you want to add additional benefits?

Coverage Limit: Critically review the coverage limits of the IPD and OPD. Ensure that the limits align with healthcare needs and financial suitability. Consider whether it covers pre-existing conditions, the risk factors depending on your lifestyle, whether preventive check-ups are allowed, the deductions and exclusions, and what extra perks are available.

Network Hospitals: Make sure to go through the network hospital list and healthcare providers' details. Confirm that you have a number of options available around you offering IPD and OPD cashless treatment.

Talk to an Expert: Comparing various health insurance plans and deciding what coverage is best for you can be overwhelming. We suggest you connect with a reliable insurance advisor.

Final Words

Selecting the right healthcare coverage is crucial, as you need to check various options, compare features, and find additional perks about your health insurance plan. Also, your plan must cover inpatient (IPD) and outpatient (OPD) treatments to provide the required medical care to you and your family. Understanding the differences between IPD and OPD is the first step you take to be aware of how you can benefit from your insurance.

If you need help from a reliable health insurance agent, RenewBuy Advisor Connect can help you find one near you.