Summary of this article
OPD coverage increases health insurance premiums by roughly 15–40 per cent.
Regular consultations, diagnostics, and medicines make OPD insurance valuable for families.
OPD cover pays off when annual routine expenses exceed the extra premium.
Low medical users may not benefit from adding OPD insurance coverage.
Your medical insurance will cover your hospitalization expenses, but it will not cover outpatient department (OPD) bills or expenses for medicines. Here is where an OPD cover comes in. However, it is essential to determine whether the additional premium is worthwhile. Let’s take a look.
“It is common for many health insurers to only cover expenses associated with inpatient care (such as surgery or hospitalization), and this limited coverage leaves many people without a viable option for medical care during their weekly or monthly appointments,” says Ramamurthy, co-founder, Staywell Health.
What OPD Cover Includes And What It Means For Your Premiums
Milind Tayde, Head - employee benefits, Anand Rathi Insurance Brokers told Outlook Money that the addition of OPD coverage can raise the premium by 15 to 40 per cent.
“Introducing coverage into a standard health insurance policy, whether as an add-on or as part of a standalone product, typically results in a premium increase of approximately 15-40 per cent. This variation usually depends on plan coverages, expected utilization patterns, and the demographic profile of the insured group,” says Milind Tayde.
On the other hand, minimal OPD benefits typically result in a modest premium increase, while comprehensive designs covering consultations, diagnostics, pharmacy expenses, etc., are priced higher due to anticipated higher claim frequency.
Unlike hospitalization benefits, OPD claims occur far more regularly, and therefore, insurers price these benefits based on utilization probability rather than the total policy sum insured. As a result, the value of OPD cover depends largely on utilization patterns and the adequacy of sub-limits relative to actual medical expenses.
“In short, OPD benefits make health insurance more practical and accessible for day-to-day medical needs; however, they do come at a price, and the decision to include them should balance affordability with actual usage patterns,” says Tayde.
Does It Make Sense To Pay Extra For OPD Insurance
Whether the decision to pay the added cost for OPD coverage is financially sensible or not depends on how much a household typically spends on routine medical needs per year. These expenses include doctor consultations, prescribed medicines, diagnostics, and minor procedures, usually these items that are generally excluded from standard hospitalization policies. Increasingly, corporate employers have begun offering OPD protection as an optional or voluntary benefit for employees.
A recent study by Policybazaar indicates that annual OPD spending for urban policyholders typically ranges from Rs 3,000 to Rs 20,000, depending on age, family size, and existing health conditions.
Younger individuals with limited medical requirements tend to fall at the lower end of this range, while households with children, elderly dependents, or chronic lifestyle conditions may incur significantly higher recurring costs.
OPD cover demonstrates clear value when the incremental premium is equal to or lower than expected annual OPD expenditure, as it converts irregular medical outlays into a predictable financial commitment while reducing out-of-pocket exposure.
“The financial viability of OPD is directly tied to the frequency of usage. Suppose an OPD member has a high reliance on outpatient care sources and reasonable expectations for an annual visit cycle (i.e., a yearly cycle). In that case, the additional premiums associated with OPD may offset cost differences and will help provide a predictable expense level (i.e., no increased out-of-pocket expense),” says Ramamurthy.
If a member only has a low frequency of doctor visits or diagnostic tests, they may find no value in purchasing this addition to their health coverage policy.
“Analysis shows that, in essence, you pay Rs 4,800–Rs 11,000 extra annually to access benefits worth six times more—provided you use the full network, and you really need it. For families already spending Rs 50,000+ yearly on tests, consultations, and medicines, OPD cover turns irregular medical expenses into predictable, cashless spending,” says Komal Jain, personal finance professional at WealthPliers and Irdai-registered advisor.
