Rashtriya Swasthya Bima Yojana

• Enjoy options to cover yourself, your spouse, kids and even your parents
• Enjoy access to 10,000+ hospitals for cashless treatment
• Reduce your taxable income by up to Rs. 50,000 deduction under section 80D**

Rashtriya Swasthya Bima Yojana is a social security scheme started by the Government of India for unorganized workers in the country. Unorganised workers in the country get exposed to various health risks including old age, disability, general ailments, maternity etc. This health insurance scheme ensures that these workers are protected from these health hazards. This scheme was originally started in the year 2008 to provide coverage for below poverty line families. It was later expanded to include unorganized workers who belong to marginally above poverty line families.

Eligibility for Rashtriya Swasthya Bima Yojana

In order to enroll in this scheme, potential members must meet the following eligibility criteria:

• The beneficiary must belong to a below poverty line (BPL) family and must be included in the district BPL list created by the government.
• Unorganised workers who are marginally above the poverty line can also be enrolled in this scheme.
• Some of the workers who can be covered in this scheme include construction workers (registered with the Welfare Boards), railway porters, sanitation workers, domestic workers, MNREGA workers, rickshaw pullers, rag pickers, etc.
• Families that wish to enroll in this scheme must come to the enrollment center where the identity of the family head must be established.

Features of Rashtriya Swasthya Bima Yojana

Some of the notable features of Rashtriya Swasthya Bima Yojana can be given as follows:

• This scheme offers coverage for up to Rs.30,000 for various hospitalisation expenses.
• The premium charges for this medical insurance cover are paid jointly by the Central Government and the respective State Governments.
• The beneficiaries must pay Rs.30 for the registration fee and the rest will be taken care by the government.
• There is no age limit for getting benefits under this cover.
• All pre-existing conditions are covered in this scheme right from day one of commencement.
• The main focus of this cover is to reduce the out of pocket expenses incurred by underprivileged families in case of catastrophic medical emergencies.
• This is a cashless treatment scheme that reimburses the network facility based on predetermined package rates for specific conditions.
• This is a family floater cover that provides coverage for everyone in the member’s family.
• This scheme is designed as a business model that offers incentives for all stakeholders involved. The insurers get the premium amount from the government for all the members enrolled.
• The government pays up to Rs.750 per family per year as the premium amount. This helps the government provide easy access to quality healthcare for all underprivileged families.
• Families enrolled in this scheme will be issued a smart card that contains various biometric details including fingerprints. The biometric system makes this scheme safe and foolproof.
• With the help of this smart card, poor families can get cashless treatment in any of the empanelled hospitals located across the country.
• This scheme is monitored with the help of an elaborate data management system that tracks transactions across the country and sends periodic reports.

Benefits of Rashtriya Swasthya Bima Yojana

The range of the benefits offered by Rashtriya Swasthya Bima Yojana can be given in this table:

Exclusions of Rashtriya Swasthya Bima Yojana

There are no specific exclusions listed out under this scheme. However, it is understood that this coverage only applies to emergency situations faced by the insured. Any kinds of cosmetic treatments will not be covered under this scheme. For certain conditions, the coverage will apply only when there is an actual medical emergency.

Claim Procedure

This is a cashless treatment scheme offered by the Government of India. The government has effectively used information technology to issue smart cards for all beneficiaries. During the time of hospital admission, a beneficiary must provide the smart card to the hospital. Upon verification of the biometric details, the network hospital will initiate treatment for the insured person.

Claim request and settlement happens between the network hospital and the insurer. One of the significant advancements made in this scheme is the implementation of paperless initiative for all participating service providers. All claim details of the insured person can be sent to the company online. The network hospital must provide various documents including medical bills, diagnostic reports, physician certificate, prescriptions, cash memos, etc. to the insurer. Upon verification of these details, the insurer will transfer the claim amount (package rate) to the network hospital.