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Rashtriya Swasthya Bima Yojana

Rashtriya Swasthya Bima Yojana is a useful government-sponsored health insurance product that offers coverage to families that fall in the Below Poverty Line (BPL) category. The benefits under the scheme can be availed by paying an affordable premium. Also, there is no maximum entry age to be covered under this scheme.

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Rashtriya Swasthya Bima Yojana

Launched by the Ministry of Labour and Employment, Government of India, the Rashtriya Swasthya Bima Yojana aims to provide health insurance coverage to the families that fall in the Below Poverty Line (BPL) category. The scheme offers protection to households against financial liabilities arising due to health emergencies that lead to hospitalisation.

What is Rashtriya Swasthya Bima Yojana?

Rashtriya Swasthya Bima Yojana (RSBY) Or National Health Insurance Programme is a government sponsored scheme especially designed for the BPL section of the society. Financed majorly by the Indian government (75%), the scheme is partially financed by the respective state government. In case of north-eastern states and Jammu and Kashmir, the Government of India contributes 90%, whereas the respective state governments contribute 10% of the premium.

The beneficiaries are required to pay a minimal registration fee of Rs. 30, which shall be used to cover administrative expenses under the scheme.

Given below are the eligibility criteria for Rashtriya Bima Yojana:

  • Unauthorized workers belonging to BPL category and their family members (up to 5 members) shall be the beneficiaries under the scheme.

Note that the implementing agencies will be required to verify the eligibility of the unorganized sector workers and their family members who are proposed to be covered under the policy. For identification purposes, the beneficiaries will be issued smart cards.

Features of Rashtriya Swasthya Bima Yojana

Rashtriya Swasthya Bima Yojana is a beneficial health insurance product. Following are the features of the policy that you must know:

1. Easy Access to Healthcare Facilities

Rashtriya Swasthya Bima Yojana is especially designed for people who fall in the Below Poverty Line category in India. As they do not usually get the required treatment in case of accidental injuries or treatments, therefore the policy does its bit by eliminating such situations to a great extent.

2. Affordable Premium

The premium for Rashtriya Swasthya Bima Yojana is very less. Any person who meets the eligibility criteria can avail of the policy benefits by paying a registration fee of Rs. 30. The Central Government and the respective state governments pay the rest of the amount i.e. Rs. 750 jointly.

3. No Limit on Maximum Entry Age

Unlike regular health insurance plans, there is no limit on maximum entry age to apply for Rashtriya Swasthya Bima Yojana. This means an eligible can enroll under the policy no matter what his/her age is.

4. Option to Choose

The policyholders of RSBY can avail of the required treatment in any empanelled hospital of their choice. It is not mandatory to avail of treatment at a public hospital.

5. Technology and Security Enabled

As RSBY health insurance scheme uses robust monitoring and evaluation with IT-enabled applications and chips on the smart card. The cards have biometric information of the policyholders and ensure quick data exchange as they are connected to the servers at the local level. With the help of a high-security system, it is easy to keep track and report on a frequent basis.

6. Beneficial For All Stakeholders

RSBY is designed in such a manner that not only the beneficiary and his/her family benefit from it, but the stakeholders benefit from it too. The stakeholders receive incentives, including MFIs and NGOs.

Inclusions Under Rashtriya Swasthya Bima Yojana

Rashtriya Swasthya Bima Yojana covers the insured for the following healthcare expenses:

1. Hospitalisation Expenses

Hospitalisation expenses arising due to treatment of an illness, disease, sickness, or an accident are covered under the RSBY. Note that the health insurance company will cover the following hospitalisation expenses, provided the hospitalisation takes place in a nursing home/hospital by a qualified physician/medical practitioner/ medical specialist:

  • Nursing and boarding expenses
  • Bed expenses for general ward
  • Doctor’s consultation
  • Anesthetics
  • Consultation fee
  • Surgeon’s expenses
  • Implants
  • Oxygen
  • OT expenses
  • Expenses related to use of surgical appliances
  • Prosthetic devices
  • X-ray and diagnostic test
  • Expenses related to food for the patient

2. Pre-Hospitalisation Expenses

The policy covers the insured for expenses incurred before getting hospitalised, for up to 1 day.

3. Post Hospitalisation Expenses

The policy covers the insured for expenses incurred after hospitalisation, on the treatment for which the patient was admitted to the hospital. This benefit is offered for up to 5 days after hospitalisation.

4. Transportation Expenses

The policy covers the insured for transportation expenses for up to Rs. 100 per visit. The annual limit to avail this benefit is of Rs. 1,000.

5. Expenses Arising Due to Dental Treatment

The policy covers the insured for dental treatment arising due to an accident.

6. Daycare Treatments

Daycare treatments are those that require hospitalisation of less than 24 hours. Some daycare treatments covered under RSBY are as follows:

  1. Ear surgery
  2. Dental surgery required due to an accident
  3. Eye surgery
  4. Genital surgery
  5. Contracture release of a tissue
  6. Gastrointestinal surgeries
  7. Hydro surgery
  8. Haemo-dialysis surgery
  9. Lithotripsy
  10. Throat surgery

7. Expenses Related to Maternity

RSBY covers the insured for expenses incurred due to deliveries (both natural and caesarean). The expenses covered are of Rs. 2,500 for natural delivery and Rs. 4,500 for caesarean delivery. Also, complications arising before delivery are covered too.

Note that the policy also covers the insured for expenses arising due to involuntary termination of pregnancy, caused due to an accident, or in case a situation arises where saving the mother is necessary.

8. Newborn Coverage

In case the number of beneficiaries has exceeded, even then the policy will cover the expenses related to newborn baby, until the policy term. It is up to the policyholder if he/she wants to include the baby under the policy or not, at the time of renewal.

Exclusions Under Rashtriya Swasthya Bima Yojana

Rashtriya Swasthya Bima Yojana does not cover the insured for the following healthcare expenses:

  • Expenses incurred for treatment of HIV/AIDS
  • Any claim for hospitalisation that is not covered under the policy will not be approved
  • Expenses related to hormone replacement therapy
  • Dental treatment that is corrective or cosmetic in nature are not covered
  • Expenses incurred on treatment of illness due to excessive use of alcohol, drugs, etc.
  • Congenital external disease
  • Expenses related to vitamins or tonics unless are a part of treatment, and recommended by a certified medical practitioner
  • Change of gender treatments
  • Fertility, assisted conception procedures

Rashtriya Swasthya Bima Yojana Enrollment Process

The enrollment process for RSBY starts with providing the electronic list of eligible BPL households to the insurance companies permitted to offer this scheme, using a pre-specified data format. The insurance companies, with the help of district-level officials, prepare an enrollment schedule for every village.

Going by the schedule, the BPL list is posted in every village at the enrollment station and the date and location of enrollment is published in advance. Mobile enrollment stations are set up at prominent places such as public schools, etc. The stations are equipped by the insurance company with the hardware that helps to collect biometric information and photographs of the families covered. They also have a printer to print smart cards with a photograph.

The beneficiaries are provided with a smart card as well as an information pamphlet that has all the information about the scheme including the list of network hospitals, once they pay Rs. 30 as registration fee. The cards are provided in a plastic cover. The process is simple and not time taking. It will just take ten minutes for the entire process to be completed.

Rashtriya Swasthya Bima Yojana Smart Card

Smart cards play an important role as it allows cashless transactions at the network hospitals. With a smart card, the insured can also avail of portability benefits across India. Other activities that a smart card can be used for include patient information, identification of the beneficiary through fingerprints, photograph, etc. the photograph on the smart card can also be used for identification in case the biometric information fails. The beneficiary will get the smart card at the enrollment station.

Rashtriya Swasthya Bima Yojana Claim Process

After availing of the required treatment, the beneficiary is required to send an electronic report to the insurance company or the Third Party Administrator (TPA). The insurance company or the TPA then goes through the record information and makes the payment to the hospital when the stipulated time as decided by the insurance company and the hospital.

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