The most common type of coverage in health insurance is the one where people get reimbursed for hospital admission for over 24 hours. This type of coverage is known as hospitalisation coverage, and it compensates the insured person for the medical expenses incurred during the hospital stay. In addition to hospitalisation coverage, many comprehensive health insurance plans of the recent days have provisions for both day care treatments and outpatient department (OPD) treatments. However, these treatments are subject to the discretion of the insurer, and they vary from one company to another.
Technological advancements in the field of medicine has shortened the treatment duration of many procedures. This has made various medical expenses inadmissible for a claim. This is the main reason why many health insurers introduced coverage for day care and OPD treatment. There is a subtle difference between what counts as a day care treatment and OPD treatment. Hence, the distinction is clearly stated by various health insurers. Let’s see in detail the major differences between day care treatment and OPD treatment.
Day care procedures refer to treatments that do not require 24 hours of hospitalisation. For instance, procedures like dental surgery or cataract treatment are no longer complex enough to warrant more than 24 hours of hospitalisation. In most cases, these patients are discharged within just a few hours. Under these circumstances, a medical insurance plan that covers only hospitalisation expenses may not be able to provide coverage for these treatments. Day care treatment coverage, on the other hand, ensures that policyholders receive compensation even for these procedures.
Some of the common day care treatment procedures include dialysis, chemotherapy, tonsillectomy, cataract surgery, dental surgery (following an accident), etc. Most insurers have clear guidelines on what type of day care treatments are covered under their policies. Some insurers provide coverage for all kinds of day care procedures except for cosmetic or aesthetic treatments. When buying an insurance policy, you must check the range of procedures covered under a specific policy. With the right insurance coverage, you can ensure that your medical expenses are reimbursed even if they do not require 24-hour hospitalisation.
The major between OPD treatment and day care treatment lies in the type of hospitalisation required for a condition. Day care treatments may not require 24-hour hospitalisation, but they involve at least some level of hospitalisation. For instance, during a cataract surgery, a patient gets admitted in a hospital but discharged within a few hours. OPD treatment, on the other hand, requires almost no hospitalisation at all.
In OPD treatment, you simply visit a medical practitioner and get treated/diagnosed for a specific condition. For instance, a cataract surgery may count as a day care treatment but the diagnosis made for cataract counts as OPD treatment. It is not very common for an insurer to provide coverage for OPD expenses. Only a handful of companies operating in the market provide some level of coverage for the OPD expenses incurred by policyholders. Some of the top insurers like Apollo Munich, Star Health, etc. have plans that include OPD coverage.
If you are looking for a health insurance plan that offers OPD coverage, there are certain things that you have to bear in mind.
There is no denying that OPD treatment coverage has its own set of benefits. The benefits offered here may come in handy when you need to spend so much on diagnosis, physician consultation, and medicines. However, it is worth noting that medical insurance policies with OPD coverage are typically more expensive. You must make sure that the benefits are adequate when you subscribe for policy that covers OPD treatment.
The claim settlement process involved in day care treatment and OPD treatment follows more or less the same process as in hospitalisation reimbursement. In most cases, day care treatments are planned earlier by the policyholder. In case of planned treatments, the policyholder can contact the insurer and check out the possibility of cashless treatment. For instance, procedures like chemotherapy requires scheduled visit to the hospital. By automating the treatment with cashless payment, the beneficiary can get easy access without worrying about bill settlement.
OPD coverage, on the other hand, is an indemnity benefit that cannot be accessed through cashless treatment. In order to make a claim, the policyholder must submit all the relevant documents including bills and pharmacy receipts. Without proper bills, an insurer cannot honour any claims regarding OPD treatment. Once the paperwork is submitted, the insurer will verify the claim and provide the settlement amount.
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