Outpatient cover on international health insurance

Outpatient is the benefit you will use most and the one that moves the premium most after area of cover. IPMIBenefits explains what it pays for, how insurers tier it and where the small print is.

What outpatient cover pays for

Outpatient treatment is care that does not need a hospital bed. On an international private medical insurance (IPMI) plan the outpatient benefit usually covers:

• GP and family doctor consultations
• Specialist consultations, with or without a referral depending on the plan
• Diagnostic tests ordered by a doctor: blood tests, X-rays, scans
• Prescribed medicines and dressings
• Physiotherapy and, on many plans, osteopathy, chiropractic and other therapies, usually with a session limit
• Minor procedures done in a clinic

Some care is outpatient in practice but sits under another benefit. Cancer treatment in a day unit is normally paid under the cancer benefit. Counselling and psychiatric consultations often sit under mental health. Routine check-ups when nothing is wrong sit under wellness, not outpatient, because outpatient cover is for treating a condition rather than screening for one. Routine dental and optical are separate again.

What outpatient does not usually include: anything cosmetic, over-the-counter medicines, treatment that is not medically necessary, and care for a condition the insurer has excluded. The inpatient versus outpatient guide covers where the line between the two is drawn.

How insurers tier outpatient cover

Almost every international plan starts from an inpatient core. Outpatient is the first thing added, and insurers add it in one of three ways.

• Not at all on the entry level. The cheapest plan in a range is often hospital-only. Now Health SimpleCare CORE excludes outpatient treatment, IPH Emerald Core does not include general or specialist outpatient, and Expatriate Healthcare Primary is inpatient-focused.
• Capped, then full, as you climb the tiers. Now Health WorldCare adds outpatient on Advance and raises the limits on Excel and Apex. Expatriate Healthcare caps outpatient on Primary+ Lite and pays it in full on Primary+ and Select. APRIL International sells outpatient as an option that increases by tier.
• As a module you add to any core. Allianz Care sells an out-patient module that must match the level of the core plan. HCI Nimbl offers outpatient as an optional module with its own caps and deductible choices. AXA Global Healthcare lists outpatient treatment as an upgrade.

This is why two plans with the same annual maximum can have very different premiums. One pays for every GP visit; the other pays for none. The cost guide explains why outpatient is the single biggest benefit-driven step in price.

Outpatient limits, excesses, co-payments and referrals

Outpatient is where cost sharing is used most, because the claims are small and frequent. Expect to see some or all of the following in the table of benefits.

• An outpatient sub-limit. A maximum per policy year for all outpatient claims together. On capped tiers this can be modest; on full tiers it may be paid in full up to the overall annual maximum.
• Per-benefit limits inside it. A number of physiotherapy sessions, a maximum for prescriptions, or a cap on consultations.
• A per-visit excess. A fixed amount you pay at each consultation. Now Health WorldCare, for example, offers an out-patient per-visit excess on Advance and above.
• Co-insurance. A percentage of each outpatient bill you pay. Now Health WorldCare offers 10% or 20% out-patient co-insurance; Cigna Global applies a cost share of 0%, 10%, 20% or 30% after the deductible, capped by an out-of-pocket maximum.
• Referral rules. Some plans require a GP referral before a specialist consultation is covered. Bupa Global states that no GP referral is needed to see a specialist.

Pre-authorisation is lighter for outpatient than for hospital treatment, but it is not absent. Cigna Global states that most outpatient treatment does not need pre-approval, with exceptions including genetic testing, infertility treatment, therapy sessions beyond a stated number and prescribed drugs beyond a stated period. Other insurers set their own thresholds, often for scans and for courses of therapy. The excess and cost-sharing guide explains how these pieces add up.

Direct billing, networks and pay-and-claim

How you pay for an outpatient visit depends on the insurer's network. In-network, many insurers can bill the clinic directly, so you show your membership card and leave without paying. Cigna Global, for example, states that in-network outpatient visits can often be billed directly. Out of network, or with insurers that do not offer outpatient direct billing, you pay the clinic and claim back through an app or portal.

Pay-and-claim is not a problem for a single GP visit, but it adds up if you have regular physiotherapy or ongoing prescriptions. If you expect to use outpatient cover often, check whether the clinics you would actually visit are in the insurer's network, and how reimbursements are paid. Usual and customary charges are another quiet limit: AXA Global Healthcare states that charges must be usual and customary for the country of treatment, and most insurers apply a similar test, so a clinic that bills far above local norms may not be reimbursed in full.

What to check in the table of benefits

Outpatient cover, underwriting and pre-existing conditions

Most pre-existing conditions are managed as outpatients. Blood pressure checks, repeat prescriptions, specialist reviews and physiotherapy are all outpatient claims, which is why underwriting bites hardest on this benefit. Under full medical underwriting, an excluded condition means every outpatient claim connected to it is declined, including the medicines. Under a moratorium, those claims are declined until the symptom-free period has run, and because ongoing medication counts as treatment, a condition that needs regular prescriptions may never clear the moratorium.

This is the practical reason to think about outpatient and underwriting together. A full outpatient tier is only valuable for a condition the insurer has agreed to cover. If you have a condition that needs regular care, the terms you are offered matter more than the outpatient limit, and switching insurers on continued personal medical exclusions can preserve cover you already have. The pre-existing conditions guide and the chronic conditions page cover this in more depth.

Common mistakes with outpatient cover

• Choosing a hospital-only plan to save money, then paying for every GP visit and prescription out of pocket.
• Paying for full outpatient cover when you see a doctor once or twice a year.
• Comparing the annual maximum and missing that the outpatient sub-limit is a fraction of it.
• Ignoring the co-insurance percentage, which can make a full outpatient tier feel like a capped one at claim time.
• Seeing a specialist without the referral the plan requires.
• Assuming direct billing works at every clinic when it only works in the insurer's network.

Outpatient is the benefit where honest self-assessment pays. Count the visits, tests and prescriptions you had last year, and compare that against the limit and the cost sharing on each plan. Nomi can show the outpatient terms of every plan it quotes next to the premium, and the insurers IPMIBenefits compares cover the full range from hospital-only to paid in full.

Frequently asked questions

This page is general information, not personal or medical advice. Prices are indicative and confirmed by the insurer at underwriting. For advice on your situation, speak to an experienced broker.