Traditionally, health insurance plans pay policyholders in case of hospitalisation for over 24 hours for treatment of any disease or accidental injury and expenses made in association to hospitalisation including pre- and post-hospitalisation expenses on checkups and tests.
However, hospitalisation is very rare in comparison to visiting doctors in outpatient (OP) facilities. So, there has been a long-standing demand of policyholders that OP expenses should also been covered under health insurance policies.
Moreover, during policy a policy year, a healthy person is more likely to visit a doctor for medical conditions, which are not serious enough for hospitalisation than actually get hospitalised. So, OP cover would be more appealing for a healthy person to take health cover.
Although, the Insurance Regulatory and Development Authority of India (IRDAI) is also in favour of providing OP cover to health insurance policyholders, stakeholders of health insurance industry fear major payouts due to frauds.
"OPD fraud is very easy in India. Unless proper network of doctors is in place, it will be difficult to provide OPD cover," said Rajesh Dalmia, Partner, Ernst & Young LLP during Annual Insurance Brokers Summit in New Delhi.
However, to meet the expectations, leading health insurance company Star Health, has decided to launch a standalone plan specific only for outpatient procedures (OP), instead of providing the cover in traditional health insurance policies.
The all-new standalone product Star Outpatient Care policy would pay for all outpatient consultation, which starts with doctor fees and covers Diagnostic tests, Pharmacy Bills, Physiotherapy, Non-Allopathic Treatments, Dental Treatments and other therapeutic procedures.
Explaining the product, Star Health and Allied Insurance Co Ltd Managing Director Anand Roy said, "There are ailments that don't require in- patient hospitalisation and these come under outpatient care. In India, mostly, costs incurred for treating such ailments are paid by the people from their own pocket. Since such costs can be substantial at times, we, at Star Health, have introduced Star Outpatient Care Insurance Policy, which is one of its kind in the market."
This plan would cover customers in age group of 18-50 years and dependent children up to 25 years age, who are economically dependent on their parents.
Maximum six members of a family may apply for the policy, which is available in individual plan as well as family floater plan with a policy term of one year duration. The maximum sum insured under the policy is Rs 1 lakh and applicants may opt for variants like-Platinum, Gold, and Silver.
The OP plan provides coverage for all outpatient consultation expenses, incurred at Star Health network registered medical facility in India, as well as in non-allopathic facilities, such as Ayurveda, Yoga and Naturopathy, Unani Sidha and Homeopathy systems of medicines in any institute recognised by the Indian government and/or accredited by the quality Council of India/National Accreditation Board on Health.
Apart from outpatient consultation expenses, the new policy also covers diagnostics, physiotherapy and pharmacy expenses as well as ophthalmic treatment expenses arising out of accidental injuries incurred by an outpatient at any Star Health-registered medical facility in India.