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Rashtriya Swasthya Bima Yojana: Eligibility, Coverage, Benefits

Team AckoMar 21, 2024

In today’s time, the cost of healthcare facilities is skyrocketing. Even families who are privileged to bear a medical emergency find it difficult to keep up with the increasing costs of treatments. While government hospitals operate at the lowest possible costs, it may not be possible for some underprivileged families to avail of healthcare treatments. The reasons for this could range from infrastructure to transportation challenges. They may not get the treatment at the hospital of their choice. To overcome these hurdles, Rashtriya Swasthya Bima Yojana was created. It is designed to offer a helping hand to those who cannot afford the entire cost of a medical emergency.

Note: The Rashtra Swasthya Bima Yojana (RSBY) is now available as the Ayushman Bharat Yojana. It was launched by the Government of India under the leadership of Prime Minister Narendra Modi. This scheme is the world’s largest and fully state-sponsored health assurance programme.

The following article contains detailed information about the Rashtriya Swasthya Bima Yojana. Take a look:

Contents

What Is Rashtriya Swasthya Bima Yojana?
What Is Covered Under RSBY?
What Is Not Covered Under RSBY?
How is the Rashtriya Swasthya Bima Yojana scheme funded?
Features of Rashtriya Swasthya Bima Yojana:
RSBY Benefits:
How does the Rashtriya Swasthya Bima Yojana health insurance scheme work?
Eligibility For Rashtriya Swasthya Bima Yojana:
How To Make A Claim Under Rashtriya Swasthya Bima Yojana?
RSBY Enrollment Process:
Frequently Asked Questions:

What Is Rashtriya Swasthya Bima Yojana?

RSBY or National Health Insurance Programme is a government-sponsored scheme for Indian citizens that belong to the low-income strata or Below Poverty Line (BPL). The full form of RSBY is Rashtriya Swasthya Bima Yojana. This scheme can be categorised as a family health insurance where the policyholder and his/her family can avail benefits under the programme.

What Is Covered Under RSBY?

The Rashtriya Swasthya Bima Yojana is an unusual health insurance policy that provides extra benefits as compared to a commercial plan. Here are the coverages of RSBY insurance:

1. Hospitalization Expenses:

Expenses related to hospitalization for the treatment for a disease, illness, or an accident will be covered under the RSBY. This coverage will be extended to the policyholder’s family as well. However, the treatment and hospitalization shall be taken at a Nursing Home/Hospital by a qualified Physician/Medical Specialist/Medical Practitioner. The expenses related to the following (but not limited to) will be covered by the insurance company:

Nursing & Boarding Charges
Bed charges (General Ward)
Surgeons charges
Anesthetists
Doctor visits
Consultation fee
Anaesthesia
Blood
Oxygen
OT Charges
Expenses related to the use of Surgical Appliances
Medicines
Prosthetic Devices
Implants
X-Ray and Diagnostic Test
Food (patient only)
Etcetera

2. Pre Hospitalization:

The scheme, will cover the cost of diagnostic tests and medicines up to one day before a patient gets admitted to the hospital.

3. Post Hospitalization:

The expenses related to an ailment/surgery for which the patient was admitted will be covered for five days after the date of discharge.

4. Transportation Expenses:

The policyholder can claim a maximum of Rs.100/- per visit under transportation. The annual cap for this cost is one thousand rupees.

5. Dental Treatment:

The cost of dental treatments required as a result of an accident will be covered under the Rashtriya Swasthya Bima Yojana.

6. Daycare Treatments:

A daycare treatment is a surgical procedure that does not require prolonged hospitalization. These are also referred to as out-patient treatments. The following (not limited to) list of daycare treatments is covered under RSBY.

Contracture release of a tissue
Dental surgery following an accident
Ear surgery
Eye Surgery
Gastrointestinal surgeries
Genital surgery
Haemo-Dialysis
Hydrocele surgery
Identified surgeries under general anaesthesia
Laparoscopic therapeutic surgeries allowed under daycare
Lithotripsy
Minor reconstructive procedures of limbs
Nose surgery
Parenteral Chemotherapy
Prostate surgery
Radiotherapy
Surgery of urinary system
Throat surgery
Tonsillectomy
Treatment of fractures/dislocation
Screening and follow up care including medicine cost with and without diagnostic tests
Any procedure covered by the insurance company

7. Maternity Benefit:

Both – natural and caesarean type of deliveries are covered under this scheme. A claim for Rs. 2500 for natural and 4500 for caesarean delivery can be made by the policyholder. Any complications before delivery are also covered.

The cost of involuntary termination of pregnancy that was caused due to an accident or in a situation where saving the life of the mother is necessary, will be covered.

8. Newborn Coverage:

The new-born baby will be added automatically to the RSBY policy even if the number of beneficiaries has exceeded. This coverage will be valid until the end of the policy period. The decision of including the baby in the policy at the time of renewal, lies with the policyholder.

Also, read: Do’s and Don’ts of Buying Health Insurance Policy

What Is Not Covered Under RSBY?

The Rashtriya Swasthya Bima Yojana facilitates underprivileged people to avail necessary treatment during a medical emergency. Thus, the following conditions are not covered under the plan:

Any claim for hospitalization that is not covered under the scheme will not be honoured
Cost of vitamins or tonics unless prescribed as a part of treatment by a certified medical practitioner
Dental treatments that are cosmetic or corrective in nature will not be covered. Also, root canal, filling of cavity, or procedures related to wear and tear are not covered.
Congenital external diseases
Substance abuse: Any illness arising out of excessive use of alcohol, drugs, or any intoxicating substance is not covered.
Fertility, sub-fertility or assisted conception procedures
Physical changes for resembling the opposite sex
Hormone replacement therapy
Plastic/cosmetic surgery unless required due to an accident or as a part of a disease
Vaccinations
HIV/AIDS
Suicide
War, an act of a foreign enemy, invasion, or warlike operations by nuclear materials
AYUSH
Treatments availed at a convalescent hospital, health hydro, convalescent home, nature care clinic, etc as described in the policy documents.

Exclusions Related to Maternity Benefit:

Prenatal expenses
The cost of voluntary termination of pregnancy
Hospitalization ended 48 hours after delivery and related operations

How is the Rashtriya Swasthya Bima Yojana scheme funded?

The Rashtriya Swasthya Bima Yojana provides health insurance to low-income families and is sponsored by the central government.

For most states:

70% of the cost is borne by the Government of India
30% by the State Governments

For north-eastern states and Jammu & Kashmir:

90% cost borne by the Government of India
10% by respective State Governments

The people covered under the scheme have to pay only Rs 30 as a one-time registration fee, which covers administrative expenses.

The central and state governments mainly fund the scheme, while the beneficiaries pay only a nominal registration charge. This ensures low-income families get health insurance at low costs.

Features of Rashtriya Swasthya Bima Yojana:

RSBY is much more than a basic health insurance product. It is a beneficial business model as well. Here are the features of this plan:

1. Guaranteed Treatment:

Rashtriya Swasthya Bima Yojana has been created for people who are below the poverty line of India. They may not always get the required treatment for accidental injuries or illnesses. This scheme aims to eliminate such situations to a great extent.

2. Low Premium:

An eligible person can enrol in the scheme by paying Rs. 30 as registration fee for availing the coverage offered by the health insurance policy. The remaining premium amount i.e. Rs.750 per family per year will be borne jointly by the Central Government and the respective State Governments.

3. No Age Limit:

Unlike commercial health insurance policies where an entry age is specified, here an eligible person belonging to any age group can enrol under the plan.

4. Option To Choose:

The policyholder may choose to avail treatment at an RSBY empanelled hospital of his/her choice. There is no condition for availing treatment at a public hospital.

5. Beneficial For All Stakeholders:

Not only does the policyholder and the family benefit from the RSBY scheme but also everyone who is involved in providing this service to the policyholder. The scheme is designed in such a way that each stakeholder will receive incentives, including NGOs and MFIs.

6. Technology And Security Enabled:

The RSBY health insurance scheme uses robust monitoring and evaluation with the help of IT-enabled apps and chips present on the smart card. These cards have the biometric information of the policyholder and are connected to servers at the local level for faster exchange of data. Biometric information and transaction records are managed with the help of a high-security system that keeps a track and carries out frequent reporting.

Also, check: ABHA Health ID Card

RSBY Benefits:

The following benefits make the RSBY unique and popular. Millions of families have enrolled under this scheme to date. Here are the benefits of the plan:

1. Sum Insured:

One can claim up to Rs. 30000 for various expenses that are covered under the policy.

2. Coverage For The Family:

A typical Indian family of five members can benefit from this plan. The head of the family, spouse and three dependents are covered under the plan. A newborn baby can become an additional beneficiary until the expiry of the policy.

3. No Waiting Period:

A waiting period is a time when a policyholder cannot make a claim against certain conditions as specified by the insurance company. One needs to bear the cost of treatment from their own pocket during the waiting period. However, the RSBY does not have any such clause.

4. Pre-existing Diseases:

As the name suggests, a pre-existing disease is any ailment suffered by the policyholder or the beneficiaries before purchasing the policy. This includes the diseases that the policyholder may not be aware of when purchasing the policy.Usually, in health insurance policies a waiting period of 2 to 4 years is imposed on pre-existing diseases. However, these are covered under RSBY irrespective of the age of a beneficiary from the date of purchase.

How does the Rashtriya Swasthya Bima Yojana health insurance scheme work?

Here is how the scheme works.

Insurance companies enter a bid to provide coverage under the scheme. Both public and private companies are allowed to bid. The one quoting the lowest premium per family per year is selected to provide insurance in each district.
State Governments prepare a list of eligible (BPL) families who will receive health insurance benefits.
The selected insurance company announces enrollment dates for eligible families.
Mobile enrollment stations are set up in every village for beneficiaries to enrol.
Beneficiaries enrol by providing biometric details and photographs. They pay a registration fee and receive a smart card. They also get information pamphlets on hospitals where cashless treatment is available.
A government official and insurance company representative are present during enrollment to verify and authenticate each smart card.
The final list of enrolled families is shared with the state nodal agencies to maintain records.

BPL families are identified, the insurance company is selected through bidding, and beneficiaries are enrolled at local centres and issued smart cards for cashless insurance coverage.

Eligibility For Rashtriya Swasthya Bima Yojana:

Only the family that fulfils the eligibility criteria of the RSBY is allowed to enrol under the scheme. Here is the eligibility required for RSBY:

The members of a family that are listed in the Below Poverty Line list created by the State government can enrol in this scheme
The applicant could be a worker at any unorganized sector
Registered member of the welfare boards

How To Make A Claim Under Rashtriya Swasthya Bima Yojana?

The claims made under RSBY are mostly cashless in nature. A beneficiary of this policy needs to produce the Smart card at the hospital. Note that only a hospital empanelled under RSBY can settle cashless claims. The hospital will send the necessary information to the Third Party Administrator (TPA) or to the insurance company. The claim will be settled between the hospital and the insurance company/TPA after the process of verification is complete. No paperwork is required at the time of claim settlement.

RSBY Enrollment Process:

Insurance companies that are permitted to offer this scheme will roll out a schedule for enrollment at the village level. The schedule will be made available at all possible government centres prior to the commencement of the enrolment process.

Members of the BPL list can reach the enrollment centres on the date and time mentioned in the schedule. The enrollment centre will also be equipped to print the RSBY Cards. A listed beneficiary can get the swasthya bima card as soon as ten minutes after the RSBY registration process.

The Rashtriya Swasthya Bima Yojana card status will be active soon after registration. Along with biometric details, the smart card will also carry RSBY Customer Care Number. Rashtriya Swasthya Bima Yojana hospital list will be available at the particular enrollment centre as well.

Frequently Asked Questions:

Here are few questions and answers about Rashtriya Swasthya Bima Yojana

Where can I get the application form for RSBY?

You can download the Rashtriya Swasthya Bima Yojana Application Form Pdf from your respective state government’s website.

Why are the beneficiaries charged Rs. 30 when the government is paying for the scheme?

The amount borne by the beneficiaries i.e. Rs. 30 is simply the registration fee that helps the Nodal agency to cover the administrative costs. The actual premium of the policy is borne entirely by the Central and State Government of India.

What is the age limit for dependent children to be covered under RSBY?

There is no age limit on the children of the policyholder under RSBY. However, if more than two children are present in a family the policyholder needs to decide which of them will be covered under the plan.

Whose biometric information is required at the time of medical emergency?

Any beneficiary can give their biometric information at the time of hospitalisation or claim. The presence of the head of the household is not mandatory at the hospital.

What kind of endorsements are allowed in the smart card in the middle of the policy period?

Addition and removal of family members is allowed in the middle of the policy period only in case of death and newborn child. An additional member of the immediate family can be added only in case of the death of a beneficiary.

Who can enrol under Rashtriya Swasthya Bima Yojana?

Any member belonging to the below poverty line can enrol under this scheme. This plan is beneficial especially for rickshaw pullers, rag pickers, mine workers, sanitation workers, drivers of commercial workers, etc.

Can migrant workers benefit from RSBY in any part of India?

Yes, migrant workers and their families covered under RSBY can benefit from the scheme anywhere in India. The scheme is designed to be portable across the country, allowing beneficiaries to use their smart card to avail medical services in any empanelled hospital, regardless of the state.

How does one renew their RSBY coverage each year?

RSBY coverage must be renewed annually. Beneficiaries are required to visit the enrollment centre during the scheduled enrollment period in their area. They must bring their RSBY smart card and pay the registration fee of Rs. 30 to renew their policy for another year.

What happens if an RSBY card is lost or stolen?

In case an RSBY card is lost or stolen, the beneficiary should immediately inform the nearest enrollment centre or contact the RSBY customer care number. A replacement card may be issued upon verification of identity and payment of a nominal fee, if applicable.

Are there any specific hospitals where RSBY beneficiaries must go for treatment?

RSBY beneficiaries can seek treatment at any hospital that is empaneled under the scheme, including both public and private facilities. The list of empanelled hospitals is available at enrollment centres and on the RSBY website for reference.

How is the RSBY scheme funded?

The RSBY scheme is funded through a combination of contributions from the Central Government and State Governments and a nominal registration fee paid by the beneficiary.

Can beneficiaries choose any treatment under RSBY?

Beneficiaries can avail treatments that are covered under the RSBY scheme, which primarily includes hospitalisation expenses, certain daycare procedures, and maternity benefits. However, treatments that are cosmetic, elective, or not medically necessary are not covered.