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UHIS: Universal Health Insurance Scheme: Eligibility, Coverage And Benefits

Team AckoFeb 21, 2024

Among the ambitious government health insurance schemes in India, Universal Health Insurance Scheme (UHIS) is a coverage for lower-income groups, especially the main income-earner of the family. The health insurance covers medical costs, personal accident coverage to the main income earner of the family and compensation to the family if they pass away. Read ahead to know about the Universal Health Insurance Scheme’s eligibility, coverage and benefits.

Universal Health Insurance Scheme

Contents

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What is the Universal Health Insurance Scheme (UHIS)?

In 2003, the Ministry of Health and Family Welfare launched the UHIS throughout the country to cover medical expenses of the poorest of the society. The scheme was introduced as part of the ministry’s Universal Health Assurance Mission (UHAM) for persons categorised under the Below Poverty Line (BPL) and Above Poverty Line (APL).

The primary objective of the scheme is to improve access to free medical care, especially the vulnerable section of society. Apart from medical expenses, it also provides benefits such as personal accident insurance cover to the primary income-earner and compensation to the family in case of death of the breadwinner.

Features of The Universal Health Insurance Scheme (UHIS):

Below are the features of the Universal Health Insurance Scheme launched by the Government of India:

  • The scheme is available to both individuals and groups.

  • It will be in the name of the primary earning member of the family and contains the name of family members.

  • If it’s a group policy, then it will be in the name of the group, association or the institution. The policy will consist of the name of the member and their family.

  • In a group policy, members cannot be a part of multiple group health schemes.

Benefits And Coverage Of The Universal Health Insurance Scheme:

With the main objective of covering medical expenses arising out of hospitalisation for diseases, illnesses or injury sustained by the insured person. Below are the benefits of the Universal Health Insurance Scheme (UHIS):

Hospital BenefitsCriteria
Room and Boarding Costs Per Day0.5% of the Sum Insured
Room and Boarding Costs Per Day (ICU)1% of the Sum Insured
Cost of Surgeon, Medical Practitioners, Anaesthetist, Consultants, Nursing, Specialist15% of the Sum Insured Per Injury or Illness
Cost of Oxygen, Blood, Medicines, X-Ray, Surgical Appliances, Anaesthesia, Chemotherapy, Etc.15% of the Sum Insured Per Injury or Illness

Other benefits of the scheme:

  • Rs.30,000 hospitalisation benefit per family per policy which includes the maternity benefit mentioned above.

  • Maximum expenses claim is restricted to Rs.15,000 excluding maternity benefits.

Personal Accident Cover:

In case the head of the family who is named as the main policyholder of the scheme dies, then the insured will receive Rs.25,000. This is in the case where the insured or the income-earner of the family sustains injury due to a mishap and if it leads to death within 6 months of its occurrence.

Disability Compensation:

Under this benefit, if the primary policyholder or the spouse is hospitalised because of an illness, disease or accident, then after a waiting period of 3 days, the insurer will pay Rs.50 per day from the fourth day of being hospitalised as compensation. However, the maximum is limited to 15 days per policy period.

Preventive Health Check-Ups:

The Universal Health Insurance Scheme covers the costs for routine preventive health check-ups for the insured member up to a certain annual limit per insured individual. As mandated by regulatory guidelines, the tests/check-ups covered under this may include basic blood work, health risk assessments, and cancer screening tests like Pap smear, mammography, etc. This benefit is helpful for the insured to avail of periodic health screenings, which can aid in the early detection of illness.

No Claim Bonus:

The scheme includes a no claim bonus at renewal, wherein, if no claims are made by any insured member under the policy during that policy year, a 10% increase in the sum insured shall be offered during the next renewal. This incentive motivates policyholders to undertake preventive health check-ups and maintain good health.

Ambulance Cover:

The Universal Health Insurance Scheme covers expenses incurred on ambulance transportation. The ambulance may be ground, air or water transportation. However, this cover excludes expenses for non-allopathic treatment unless the particular form of alternative treatment has been agreed explicitly for coverage under the policy terms and definitions.

What Is Not Covered/Exclusions In The Universal Health Insurance Scheme:

Below is the list of exclusions in the health scheme:

  • Disease or injury due to war, an act of terrorism, or invasion.

  • Circumcision is included only in the case of necessary treatment or disease or in case of an accident.

  • Expenses related to spectacles, hearing aids, contact lenses are not covered.

  • Dental surgery or treatment for corrective, cosmetic or aesthetic purposes.

  • Venereal or congenital diseases.

  • Cost of vitamins or tonics unless required for medication purposes.

  • HIV/AIDS

  • Death or injuries caused due to nuclear weapons.

  • Injuries due to self-inflictions.

  • Attempted suicide.

  • Suicide.

  • Injuries or death arising out of the influence of alcohol or drugs.

  • Injuries or death while operating an aircraft or taking part in adventure sports.

  • Injuries or death caused due to breaching the law with criminal intent.

Also, read: Arogya Sanjeevani Health Insurance

Universal Health Insurance Scheme Premium Rates:

Below is the table with the premium rates of the Universal Health Insurance Scheme (UHIS):

For Below Poverty Line (BPL) Families:

CoveragePremium Rate (Rs.)Insured Share (Rs.)Government Subsidy (Rs.)
Individual300100200
Up to 5 Family Members450150300
Up to 7 Family Members600200400

For Above Poverty Line (APL) Families:

CoveragePremium Rate
IndividualRs.365
Up to 5 Family MembersRs.548
Up to 7 Family MembersRs.730

Eligibility Criteria For The Universal Health Insurance Scheme:

The eligibility to avail the UHIS is based on whether the insured comes under the BPL or the APL category. Below are the details:

Eligibility Criteria For BPL Families:

  • Family’s income should not be more than the sum insured amount.

  • Proof of Certificate from the local Tehsildar or BDO of the Revenue Department confirming that the family falls under the BPL category.

  • Should be between the age of 5 to 70 years.

  • Children between 3 months and 5 years will be covered if the parents are covered under the scheme.

Eligibility Criteria For APL Families:

  • Family’s income should exceed the sum insured amount.

  • Should be between the age of 5 and 65 years.

  • Children in the age between 3 months and 5 years will be covered if the parents are covered under the policy.

  • If you already have certain health conditions before signing up, those specific illnesses may not be covered for the first 2 years. But you can still get coverage for new illnesses or accidents after joining the scheme.

  • Don't be that person who renews their policy late! As long as you continue before the due date, you can enrol again, no matter your age. But miss the date and you might have to review the eligibility criteria again. Set a reminder so you can keep coverage!

How To Enrol In Universal Health Insurance Scheme:

To enrol in the UHIS, you need to approach the concerned insurance provider who will help in applying for the scheme.

Documents Required To Apply For The Universal Health Insurance Scheme:

A Certificate of Proof that you fall under the category of BPL from an official not below the rank of Tehsildar or B.D.O of the Revenue Department belonging to the respective state government.

Also, read: Health Insurance for COVID-19

Universal Health Insurance Scheme Hospital List:

You’ll have to contact the insurance company who has their exclusive list of hospitals which cover patients under the Universal Health Insurance Scheme.  These medical centres and hospitals have partnered with your insurer to offer treatment to UHIS members like yourself. Make sure to go to only one of these network hospitals, or you might have to foot the bill yourself! Your insurer should have a big list of hospitals nationwide that have signed on to provide inpatient care under this scheme.

Wrapping up!

The Universal Health Insurance Scheme aims to make healthcare more affordable and accessible for vulnerable low-income populations. This government scheme seeks to safeguard the poorest citizens against catastrophic health expenditures by covering hospitalisation expenses and offering additional benefits like personal accident cover and preventive health check-ups. Though not without exclusions, the scheme overall represents a step towards universal health assurance and social protection for weaker sections of Indian society.

Frequently Asked Questions:

Below are some of the frequently asked questions about the Universal Health Insurance Scheme:

Is there a free look period in the Universal Health Insurance Scheme?

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Yes, all individual policies except for those with less than 1-year tenure shall have a free look period of 15 days from the commencement date of the policy to review the terms and conditions.

Will I get a refund of the premium if I decide to cancel the policy within the free-look period?

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Yes. However, the insured should have not have raised any claim during the free look period.

What is Claims Minimisation Clause?

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Under the clause, the insured will cooperate with the Third Party Administrator or Company to contain the claims ratio through fair treatment charges.

Can maternity benefit be availed for the second child under this scheme?

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No. The benefit is extended only to one child under the Universal Health Insurance Scheme. Also, there is a waiting period of 12 months from the date of inception of the insurance policy.

Is Naturopathy treatment covered under the UHIS?

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No. Naturopathy treatment is excluded under this scheme.

Is drug experimental therapy treatment included in the scheme?

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No. Drug experimental therapy which is not based on established medical practice in India is not covered under this scheme.

How can one enrol for the Universal Health Insurance Scheme?

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To enrol for UHIS, you must approach the concerned insurance provider, who will guide you through the application process.

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