What is the difference between day care treatment and OPD treatment

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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.

Coverage for day care 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.

Coverage for OPD treatment

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.

Things to note when looking for 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.

• OPD coverage does not provide benefits up to the whole sum insured limit. Usually, most insurers set a specific percentage limit for OPD coverage. Any expenses incurred for these treatments must be within this range.
• OPD coverage is not a standard feature in all health insurance plans. Even that ones that provide coverage for day care treatment may not offer OPD coverage. If OPD coverage is an absolute must for your requirements, you need to check the policy document carefully and choose the right one.
• Since OPD treatment is done by private medical practitioners and general physicians, the documentation process is usually poor. Insurers reimburse expenses only when the relevant bills are produced. Hence, you must ensure that appropriate bills are collected following a hospital visit.
• If you are buying OPD coverage as an add-on policy, you must ensure that the policy is worth the money spent. For instance, an add-on cover that costs Rs.6,000 per year and provide benefits to the maximum of Rs.8,000 per year is not a great choice. Hence, it is better to choose a health insurance policy that offers OPD treatment as a part of the comprehensive coverage.
• When buying OPD coverage, check out the waiting period associated with any specific procedures for which you need immediate treatment. If the waiting period is high, this cover may not be adequate for your specific usage.

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.

Claim Process

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.