Know the Benefits of OPD Cover and Maternity Cover under Health Insurance Policies


In India, a good percentage of people know the benefits of health insurance policies. Still majority of them look at health insurance as a tax saving instrument only. According to the survey of ICICI Lombard, 46% of people bought health insurance to save tax and not for the benefits it offers. Unfortunately, I still come across people who consider health insurance just like any other investment option. They cannot relate to the fact that by paying a premium of only a few hundred, they are financially securing their future.

The hesitation of individuals perhaps stems from the fact that most of the medical expenses go towards the outpatient care and other medicines, while hospitalization accounts for a small share. So what is the point of buying health insurance if it does not cover most of the expenses? However, contrary to the popular belief, there are various benefits offered by mediclaim insurance policies. Here we discuss two main benefits offered by the health insurance policy:

First Benefit: OPD (outpatient department) Cover

Not very long back, doctors charged Rs 100 or 150 for consultation, but today a consultation fee has increased to Rs 1000-1500. Even, the cost of diagnostic tests has escalated due to imported lab equipment. Usually, health insurance companies cover hospitalization expenses, but with the advancement in the medical field, there are only a few procedures left that require staying in the hospital. Look at the case of Mr. Raj’s 10-year old son who was diagnosed with dengue. The cost of doctor consultations and medical tests crossed Rs 15,000. However, since there was no hospitalization, these expenses were not covered under the health insurance policy.



To bridge this gap, it is advised to go for a mediclaim plan that covers out-patient department (OPD) expenses like doctor’s consultation fee, pathological tests, medicines, etc. Mainly, an OPD is a hospital department where patients receive medical treatment but do not stay overnight. As per the report of the FICCI-Feedback Consulting report titled ‘A Guiding Framework for OPD and Preventive Health Insurance in India; Supply and Demand Analysis’, the working population in India spends around 60% on the out-patient expenses every year out of their pocket. Due to high medical costs, most Indians avoid doctor visits, and here OPD cover can help.

Who should go for OPD benefits?

In the recent years, there is a rise in the number of dialysis patients who do not need hospitalization for more than 24 hours, but incur hefty medical expenses. For them, an OPD cover is very useful. It is also suitable for families who need regular medical consultations and medicines. For a family, especially with young children, monthly medical expenses on doctor’s consultation can run up bills more than Rs 10,000. Similarly, it is beneficial for people who suffer from chronic ailments or need frequent medical care. The cover is a perfect match for working professionals who do not have corporate health programmes. It is also beneficial for pregnant women who require a series of prenatal test.


Some of the key features of OPD cover are:

· It covers minor non-hospitalization expenses for medicine, day care expenses, doctor’s fees, checkup, etc.

· It also offers specialized coverage for dental treatments, spectacles and contact lenses for up to a certain limit

· The premium paid for OPD expenses is also eligible for tax benefits under Section 80D of the Income Tax Act

How to file a claim?

Usually, policyholders can claim OPD charges only once during the policy tenure. To claim OPD expenses, a policyholder will require submitting the doctor’s prescription label along with medical expenses bills. Some companies insist on a doctor’s referral because they don’t want policyholders to misuse the OPD policy by producing fake bills. Even over-the-counter medicines can be claimed after the doctor’s prescription. At the time of making the claim, the doctor’s prescription is needed.

Second Benefit: Maternity Cover

Motherhood is a crucial stage in every woman’s life. Good quality maternity care is required for both mother’s and child’s health. However, due to lower medical care, India accounted for the maximum maternal deaths in the world in 2013.

To deal with the situation, many insurers have started covering maternity under their health plans. The cover is provided as a rider on a main health insurance scheme, and you need to shell out an extra premium to get the coverage. However, some insurance companies do not charge an extra premium, but they put a waiting period and cap under the maternity cover.

Why should you avail maternity cover?

Maternity expenses are increasing in India. Today, the delivery cost can vary anywhere between Rs 25,000-Rs 1 lakh. Nowadays, women are choosing to become mothers late, and this increased age has also given birth to complications during pregnancies. To address growing maternity related concerns, it is worthwhile to opt for a maternity cover. A newly married couple can opt for a maternity cover and avail the maternity benefit when they start family planning.

While buying a maternity cover, some points should be considered:

· If you are a working professional, check whether your group health insurance offers maternity benefits or not. Most of the companies cover maternity under a group health plan from Day 1

· Most of the insurers have a waiting period of 3-6 years before they cover maternity expenses

· Insurers cover emergency pregnancy situations, like premature delivery, deformity in a newborn, etc.; also but you should check the sum insured as some insurers put a cap of Rs 50,000 on such charges

· No maternity cover is offered if you are pregnant at the time of buying the policy. Insurers consider it as a pre-existing cover, and therefore, they do not offer coverage


Source: The Economic Times

What does maternity cover include?

A maternity cover offers the following benefits:

ü It includes hospitalization expenses and the cost of delivery of the baby, both normal or caesarean

ü It covers costs related to pre and post natal care

ü The cover may include newborn baby also, up to a certain limit

ü Some insurers also cover the ambulance charges to take the patient to the nearest hospital

ü Some health plans cover vaccination and consulting charges for newborn babies


Healthcare costs can break your back, especially if you are diagnosed with a serious ailment. A comprehensive health insurance policy plays an important role in safeguarding you against hefty medical expenses. However, to get a complete benefit, it is advised to go for a comprehensive health insurance plans which cover not only OPD expenses but also maternity expenses at an affordable premium rate.