Key takeaways
Blog sources
Group Health insurance in India has evolved. It's no longer just about covering hospital stays. Today, a large chunk of healthcare costs comes from outpatient expenses like doctor consultations, diagnostic tests, and medicines none of which require hospitalization.
This is where OPD cover (Outpatient Department cover) comes in.
With more insurers offering group health insurance with OPD cover, individuals and employees now have two key options:
- Group Health OPD Insurance– An employer-sponsored benefit offered as part of group health insurance.
- Individual OPD Plan – A standalone policy for customized outpatient care.
Emerging trend:
In recent years, many employers, especially startups and SMEs have begun purchasing individual OPD plans for their employees.
What is OPD cover in group health insurance?
OPD cover helps you claim reimbursement or avail cashless benefits for medical expenses that occur without getting admitted to a hospital.
Unlike hospitalization, where treatment requires at least 24 hours of inpatient care, OPD treatments happen in a doctor’s clinic, diagnostic lab, or pharmacy. These are the healthcare expenses we face more frequently but they’re often not covered under basic group health insurance plans.
Examples of OPD expenses:
- Visiting a general physician or specialist (e.g., dermatologist, pediatrician)
- Routine blood tests, X-rays, or scans
- Buying prescribed medicines from a pharmacy
- Minor procedures like dressing, stitches, or injections
- Physiotherapy and follow-up consultations
Why It Matters: Around 70% of medical expenses in India are OPD-related. Ignoring this coverage could lead to significant out-of-pocket spending over time.
What is group health OPD insurance?
A Group Health OPD insurance is an additional benefit added to your employer’s group health insurance. It allows you to claim outpatient expenses along with hospitalization benefits.
What does it cover?
- Doctor consultations (in-network)
- Lab tests and diagnostics
- Medicine reimbursements
- Basic health checkups
Advantages:
- Cost-effective: Since the premium is negotiated at a group level, the cost per employee is lower.
- Seamless access: Usually integrated with existing employer insurance. No separate paperwork.
- No medical tests: You’re covered from day one without the need for individual health screenings.
Limitations:
- Job-dependent: You lose the OPD cover if you resign or switch jobs.
- Limited flexibility: Tied to a specific list of hospitals, clinics, and diagnostic labs.
- Lower claim limit: OPD benefits might be capped at ₹2,000–₹10,000 annually.
- One-size-fits-all: Not tailored to your personal health needs or usage patterns.
- Group Health OPD Add-on is not always budget-friendly: Even though the starting cost is low, if many employees use the OPD benefit often, the company’s renewal premium can increase a lot later.
What is an individual OPD plan?
An Individual OPD Plan is a health benefit that helps cover day-to-day medical expenses that don’t require hospitalization. These plans work like a digital OPD wallet, where the insured person gets a fixed allowance to spend on eligible OPD expenses throughout the year.
In an OPD wallet, the amount can be used flexibly across consultations, labs, or medicines, making it ideal for people who regularly need outpatient care.
What does it cover?
- Doctor consultations from any registered doctor
- Diagnostic tests & scans
- Prescribed medicines
- Optional add-ons like teleconsultation and dental care
- Mental wellness benefits
- Discounted gym memberships
- Employee assistance programs
- Health checkups & vaccinations
Advantages:
- Wider access: Most plans allow cashless visits to any registered clinic.
- Higher limits: More generous claim limits, suitable for families or individuals with ongoing medical needs.
- Add-on options: Can be bundled with maternity, mental wellness, or chronic care riders.
Limitations:
- Waiting periods: Certain services may be claimable only after 30–90 days.
- Documentation: Claims may require bills & prescriptions.
Detailed comparison: group vs individual OPD plan
“Customers are now demanding products with OPD coverage. The pandemic made people realize the need of having a comprehensive health insurance plan which not just covers hospitalization but also OPD expenses.”
📊— Prasun Sikdar, MD & CEO of ManipalCigna Health Insurance, to BusinessToday
How HRs & founders can choose the right OPD cover for their team
Here’s a step-by-step checklist to help you decide:
1. Assess employee healthcare needs
→ Review trends from previous insurance utilization (if any).
→ How often do employees or their dependents visit doctors, request diagnostics, or seek outpatient care?
Look at employee demographics like young workforce vs families with kids or aging parents may have very different OPD needs.
2. Estimate average OPD spend per employee
→ Consult your broker or TPA/insurer for usage data.
This helps you set a reasonable OPD limit per employee without overpaying on premiums.
3. Review Your Current Group Health Insurance Benefits
→ Does your current insurer offer an OPD add-on?
→ Is the network broad enough for employees in different cities?
If not, consider switching to a health insurer that offers OPD integration or individual OPD plans for teams.
4. Compare cost vs coverage across providers
→ Evaluate if paying a slightly higher premium gets you broader coverage or cashless OPD options.
Some platforms like Pazcare now offer flexible, modular benefits based on team size and usage patterns.
5. Plan for team mobility and job roles
→ Are your employees hybrid, remote, or field-based?
→ Do you have gig workers, interns, or consultants who need OPD cover but not full hospitalization plans?
Offering portable individual OPD plans or digital health memberships may suit to them.
6. Examine Policy Fine Print
→ Watch for exclusions such as:
- Non-allopathic consults (Ayurveda, Homeopathy)
- OTC medicine reimbursements
- Sub-limits on certain OPD services
Always check whether maternity, dental, or mental health consultations are included under OPD.
Final Takeaway
When it comes to OPD cover in health insurance, there is no one-size-fits-all answer.
- Group Health OPD insurance is great for employers who want to give basic, affordable coverage.
- Individual OPD plans work best if you need more flexibility & higher limits.
Choosing the right plan now can save you from surprise expenses later, especially for families with kids, senior citizens, or anyone managing lifestyle conditions like diabetes or thyroid.
Conclusion
Your health doesn’t wait for hospitalization and your insurance shouldn’t either. Whether through your company’s group health insurance or a health insurance with OPD cover, protecting your everyday health expenses is crucial.
Evaluate your lifestyle, budget, and medical history. Compare plans. Read the terms. And choose the OPD cover that fits your healthcare journey, not just your wallet.
Want to explore health insurance plans with OPD cover?
At Pazcare, we help employers and employees access affordable, flexible group health insurance and OPD benefits, doctor consultations, wellness add-ons, and much more.
👉 Talk to our team today to explore the best OPD-inclusive plans for your team.
.png)
.svg)
.svg)