How to claim outpatient department (OPD) medical expenses?

Hello,

The claim process depends on whether you have private health insurance or an Ayushman Bharat card. Please check the details below to understand which rules apply to you.

1. How to claim OPD expenses under private health insurance?

Most standard health insurance policies do not cover routine OPD expenses unless your policy includes specific OPD coverage. If your policy covers OPD expenses, you may be able to claim through these methods.

Method 1: Cashless OPD claim

1. Check whether your insurance policy includes OPD benefits.
2. Confirm which doctors, clinics, hospitals, or pharmacies are covered under your insurer's network.
3. Show your health insurance card or policy details when visiting the covered provider.
4. Follow the insurer's process for approval and cashless payment, subject to your policy limits.

Method 2: OPD reimbursement claim

1. Pay for the consultation, medicines, or diagnostic tests if cashless treatment is not available.
2. Collect the doctor's prescription, original itemised bills, payment receipts, and diagnostic reports, as applicable.
3. Download or obtain the OPD claim form from your insurance company.
4. Submit the completed form and required documents through the insurer's app, website, or claims office.
5. Check your policy for the claim submission deadline and keep the claim reference number for tracking.

Approval and payment depend on your policy terms, limits, exclusions, and the documents submitted.

2. Can you claim OPD expenses under Ayushman Bharat?

Under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), routine OPD consultations, standalone diagnostic tests, and medicines purchased outside an eligible hospitalisation package are generally not covered.

However, eligible expenses related to an approved hospitalisation package include certain pre-hospitalisation expenses for up to 3 days before admission and post-hospitalisation expenses for up to 15 days after discharge, subject to scheme rules and the approved package.

How does the Ayushman Bharat claim process work?

1. Visit a hospital that is actively empanelled under Ayushman Bharat for your required treatment.
2. Meet the Ayushman Mitra or PM-JAY helpdesk at the hospital.
3. Show your Ayushman Card or beneficiary details and a valid identity document.
4. Provide relevant prescriptions, medical reports, and bills for eligible related expenses.
5. Ask the hospital to confirm whether these expenses can be included in the approved treatment package. Standalone OPD expenses cannot generally be claimed separately under PM-JAY.

You can check empanelled hospitals through the official PM-JAY Hospital Search Portal.

Do you want to claim OPD expenses through a private health insurance policy or an Ayushman Bharat card? Also, please mention the insurance company, if applicable, and whether the expenses are for a doctor's consultation, medicines, or diagnostic tests.

Wishing you and your family good health always.
Warm regards,
Team HexaHealth