Oxford-AstraZeneca, a covid-19 vaccine for which Pune-based Serum Institute of India has tied up as a manufacturing partner, is expected to clear all trials and be available by the end of 2020. Though the vaccine is still in the advanced phases of clinical trials, Indians are waiting for it eagerly while they anticipate the possible cost. A couple of other vaccines too are in the trial phase.

“One is the procedure cost where an infected patient is hospitalized and covid-19 medicines or vaccines are administered. These costs will be covered by all health insurance policies. However, if it’s a vaccine that’s being provided on the out-patient department (OPD) basis, then only policies that pay for OPD expenses will cover it subject to being prescribed by the medical practitioner,” said Prasun Sikdar, MD and CEO, ManipalCigna Health Insurance Co Ltd.

Typically, all vaccines are covered if one has an OPD cover and insurers said the same would apply to the covid-19 vaccine as well.

Health insurance policies that come with an OPD cover are generally quite expensive and experts said this is one reason why the category hasn’t picked up in the past. Premiums for OPD policies are high because the probability of claims is higher than hospitalization and the chance of fraud also is quite high.

Sikdar said the only way to have OPD cover premiums under control is to have network providers for OPD expenses as well but since that’s not easy to achieve pan India, the OPD products then would come at a high premium.

Further, even if you have a policy with an OPD cover, there are chances of not getting the full vaccine cost covered because the OPD cover could come with sub-limits. For example, if the vaccine costs ₹1,200 and the sub-limit on vaccines in the OPD cover is ₹800, then you’ll have to bear the excess ₹400 out of pocket.

Dr Rashmi Nandargi, head-retail health underwriting, Bajaj Allianz General Insurance Co Ltd said it’s also important to check whether your OPD cover pays for vaccines or not.

Understand that just because policies with an OPD cover may pay for vaccination, doesn’t mean you must buy one. “At an industry level there are no standalone OPD covers and even the ones that come with indemnity policies, the premiums are quite high because OPD utilization would be higher than hospitalization. This is why most people prefer paying for the OPD expenses by themselves,” said Nandargi.

Typically, the differential premium charged for the OPD element is very close to the sum insured offered. For example, if the premium for a regular indemnity policy is ₹20,000, with an OPD cover with a sum insured of ₹5,000, the premium will shoot up to ₹25,000.

“Premium is higher because the insurer assumes that you would be utilizing some form of OPD services every year which is quite likely. The way plans are structured currently, it makes sense to give OPD covers a miss. As an alternative, one could look at memberships for OPD plans, which offer discounts on consultations and other benefits,” said Abhishek Bondia, MD and principal officer, SecureNow.in.