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Rashtriya Swasthya Bima Yojana

Updated on: 01 Jul, 2024 04:41 PM

Among the total workforce in India, only a small portion of the population is covered under the existing social security initiatives. Most of these people cannot afford to get quality healthcare. Also, the lack of accessibility to healthcare services results in significant challenges.

The Rashtriya Swasthya Bima Yojana is one such health insurance scheme which was launched by the Government of India for meeting the healthcare requirements of the poor people working in the unorganized sector. In this article, we will learn more about the RSBY scheme and its various aspects.

Launch of the Rashtriya Swasthya Bima Yojana Scheme

The Rashtriya Swasthya Bima Yojana was launched on 1st April 2008 by the Ministry of Labour and Employment, which is a ministry under the Government of India. It was made a part of the Ministry of Health and Family Welfare on April 1, 2015.

What is the Rashtriya Swasthya Bima Yojana Scheme?

The Rashtriya Swasthya Bima Yojana scheme provides health insurance coverage to families Below Poverty Line (BPL) categories. It also includes labourers and workers in the unorganized sector. The unorganized sector constitutes 93% of the total workforce in India. The economic burden of hospitalization due to health emergencies can be very burdensome for below-poverty-line families. The scheme pays for the medical expenses incurred by the covered members so that they can avail of quality healthcare easily without having to spend huge amounts of money on illnesses and injuries.

Eligibility Under the Rashtriya Swasthya Bima Yojana Scheme?

Rashtriya Swasthya Bima Yojana covers the following categories of individuals –

  • Workers of the unorganized sector who also belong to BPL families.
  • The family members of the workers can also be covered under the scheme. However, a maximum of 5 family members per family can be covered. The members should be the worker, spouse and up to three dependent children.

Examples of workers who are eligible to be covered under the scheme include the following –

  • MNREGA workers who have worked for more than 15 days in the last financial year
  • Sanitation workers
  • Domestic help and workers
  • Mine workers and miners
  • Rickshaw pullers, auto drivers and taxi drivers
  • Railway porters
  • Street vendors
  • Construction workers and building workers who are registered with Welfare Boards
  • Beedi workers
  • Rag pickers, etc.

What is Covered Under the Rashtriya Swasthya Bima Yojana Scheme?

The Rashtriya Swasthya Bima Yojana covers the following types of healthcare expenses –

  • Hospitalization Expenses: It covers hospitalization expenses for the treatment of diseases or accidents. It includes the boarding, nursing, surgeon, and anesthetist fees, diagnostic tests, medications, and more. However, the coverage is available only at recognized healthcare facilities.
  • Pre-Hospitalization: It covers medications and diagnostic tests upto one day before the hospital admission.
  • Post-Hospitalization: Expenses for surgery are covered upto 5 days after discharge.
  • Transportation Expenses: It reimburses the cost of Rs.100 per visit made on transportation costs, limited to Rs.1000 annually.
  • Dental Treatment: Dental treatments staking place due to accidents are covered under this scheme.
  • Daycare Treatment: It covers outpatient surgical treatments which do not require hospitalization for long time periods.
  • Maternity Benefit: It covers normal and caesarean deliveries. Policyholders can claim Rs.2500 for natural and Rs.4500 for caesarean deliveries.
  • Newborn Coverage: The policy also covers newborns. It remains valid until the end of the policy period.

What is not Covered Under Rashtriya Swasthya Bima Yojana?

  • Hospitalizations not covered under the scheme.
  • Tonics or vitamins not prescribed by a certified medical practitioner are not covered.
  • Root canals, cosmetic dental treatments, and cavity fillings are not included.
  • Congenital external diseases are not covered.
  • Illnesses resulting from substance abuse are not covered.
  • Gender-related procedures, fertility treatments.
  • Plastic surgeries are excluded until they happen due to accidents or diseases.
  • AYUSH treatments and convalescent care are also excluded.

How is the Rashtriya Swasthya Bima Yojana Scheme Funded?

The government of India contributes 75% of the estimated annual premium of Rs.750 per family, which was capped at Rs.565 annually and also covers the cost of a smart card. Remaining 25% of the annual premium is contributed by the state government.

How Does the Rashtriya Swasthya Bima Yojana Scheme Work?

The following is the step-by-step guide to how the Rashtriya Swasthya Bima Yojana scheme works –

  • Firstly, the insurance companies who would provide health insurance coverage to beneficiaries are selected through a competitive public bidding. Both public sector and private sector companies can bid to provide coverage under the scheme. The company quoting the lowest annual premium per household becomes the appointed insurer per district.
  • After the insurance companies are finalised, a list of eligible BPL families are prepared to identify the beneficiaries of the scheme. The State Governments prepare the BPL list and submit the list to the Central Government listing the eligible BPL families who are to be covered under the scheme.
  • Once the eligible BPL families are identified, a schedule of enrolment is prepared by the insurance company. The schedule contains the time and date of enrolment and it is publicized at important places so that the families can enrol themselves. Thereafter, mobile enrolment stations are set up at local centres in every village.
  • The beneficiaries can then enrol themselves by providing their biometric details and photographs. A smart card is issued to beneficiaries upon enrolment when the registration fee is paid. An information pamphlet which highlights the scheme and lists the eligible hospitals is also handed over to beneficiaries so that they can understand the scheme easily and know the hospitals where from they can avail cashless treatments.
  • A Field Key Officer, who is a Government officer, and an insurance company or smart card company representative are present at the enrolment centres. The Field Key Officer is required to insert his/her own Government issued smart card which would verify and authenticate the beneficiary’s smart card.
  • Once the beneficiaries are enrolled, the list of families who have been issued a smart card is sent to state nodal agencies for maintaining the records of beneficiaries.

Features of Rashtriya Swasthya Bima Yojana

The Rashtriya Swasthya Bima Yojana has various salient features, which are as follows –

  • The scheme provides cashless treatments to workers belonging to BPL families.
  • A smart card is issued under the scheme which enables the beneficiary to avail cashless treatment at empanelled hospitals. The smart card is also portable in nature allowing beneficiaries to avail treatment across any hospital in India.
  • BPL families can choose public hospitals or private hospitals for availing medical treatments. The hospitals which are empanelled under the scheme would have to provide cashless treatments.
  • NGOs and MFIs have been involved in the Rashtriya Swasthya Bima Yojana to act as intermediaries. The involvement of these intermediaries would ensure better and wider coverage of the scheme.
  • The Government is paying only a minimal amount of INR 750 to provide the benefits of the scheme to BPL families. Thus, by paying this low amount the Government can implement welfare oriented policies for the poor.
  • The smart cards are biometric enabled and are therefore safe and fraud proof.
  • A single smart card would be issued which would cover other Government sponsored schemes like the Aam Aadmi Bima Yojana and National Old Age Pension Scheme. The scheme involves paperless transactions as online claims are submitted to the insurance company.
  • A Central Complaint and Grievance Redressal System (CGRS) has been implemented to handle complaints and grievances of beneficiaries and to provide them with quick solutions.
  • From October 2014, enrolment in the Rashtriya Swasthya Bima Yojana has been linked to the individual opening a bank account and applying for an Aadhar card
  • There is no limit on the maximum age of the beneficiary being enrolled in the scheme. Individuals of all ages can be covered under the Rashtriya Swasthya Bima Yojana if they belong to eligible BPL families.

Making a Claim Under the Rashtriya Swasthya Bima Yojana Scheme

A claim under the Rashtriya Swasthya Bima Yojana happens when the beneficiary avails treatment at an empanelled hospital. To make a successful claim, the beneficiary should follow the following steps –

  • He/she should approach the RSBY helpdesk at the empanelled hospital.
  • The helpdesk would verify the identity of the beneficiary through the beneficiary’s photograph and fingerprints stored on his/her smart card.
  • Once the identity of the beneficiary is verified, the individual can avail cashless treatment at the hospital
  • In case of hospitalization, the representative at the RSBY help desk would check the prescribed package rate of the ailment or injury for which hospitalisation has occurred. There is a pre-specified list containing various treatments and their package rate.
  • If the reason for hospitalisation is due to an ailment or injury in the pre-specified list, the prescribed claim package is selected.
  • If the treatment is not specified in the list, the representative would check with the insurance company regarding the applicable cost of treatment.
  • The beneficiary can then avail cashless treatment at the hospital
  • When the beneficiary is discharged, his/her smart card is swiped at the RSBY helpdesk to deduct the amount of the treatment from the coverage limit available on the smart card. The hospital also pays the beneficiary INR 100 towards transportation expenses. The beneficiary does not have to submit any proof to claim transportation expenses.
  • After the treatment is done and the patient has been discharged, the hospital then sends an electronic report to the insurance company or its TPA stating the treatment done and the costs incurred.
  • The insurance company or its TPA would verify the reports submitted and pays for the treatment costs directly to the hospital. This payment is done within a specified time period which is agreed upon between the hospital and the insurance company

The Central Complaint & Grievance Redressal System Under the RSBY Scheme

Grievances relating to the Rashtriya Swasthya Bima Yojana (RSBY) scheme can be longed online using Central Complaint and Grievance Redressal System (CGRS) portal. All the stake holders can file an online complaint about the RSBY Scheme. An Online facility to track the complaint real-time is also available.

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Frequently Asked Questions

Q- What is the smart card issued under the Rashtriya Swasthya Bima Yojana scheme?

A smart card is a card which lets beneficiaries avail cashless treatment at empanelled hospitals. The card contains the biometric details of the beneficiary which enables hospitals to verify the identity of the insured member and provide cashless treatments.

Q- Whose photograph is affixed on the Rashtriya Swasthya Bima Yojana Scheme smart card?

The smart card carries the photograph of the head of the family. The photos of other family members are contained in the chip of the card which can be identified when the card is swiped upon hospitalisation.

Q- Who pays the premium for availing coverage under the Rashtriya Swasthya Bima Yojana scheme?

The premium for Rashtriya Swasthya Bima Yojana is paid by the Central and the State Governments in the ratio of 75%:25%. In case of north eastern states and Jammu and Kashmir, the ratio changes to 90%:10%.

Q- What fees does the beneficiary pay for enrolment under the Rashtriya Swasthya Bima Yojana?

The beneficiary pays INR 30 for registering himself/herself under the scheme.

Q- When is the fee payable by the beneficiary under the Rashtriya Swasthya Bima Yojana?

The fee is payable both at the time of enrolling into the scheme as well as annually every time the scheme is up for renewal.

Q- What would happen under the Rashtriya Swasthya Bima Yojana if there are more than five family members?

If there are more than five family members, besides the head of the family and the spouse, the dependent children who would be covered under the under the Rashtriya Swasthya Bima Yojana scheme will have to be selected by the head of the household. Because, the Rashtriya Swasthya Bima Yojana scheme would cover only a maximum of 5 members.

Q- Would the beneficiary be able to avail cashless treatments in a district other than the district where he/she is enrolled?

The smart card is portable and accepted at all empanelled hospitals across India. Even if the beneficiary is travelling to a different district the smart card can be used at a hospital in that district without any limitations even when the beneficiary is not registered in that district.

CA Abhishek Soni
CA Abhishek Soni

Abhishek Soni is a Chartered Accountant by profession & entrepreneur by passion. He is the co-founder & CEO of Tax2win is amongst the top 25 emerging startups of Asia and authorized ERI by the Income Tax Department. In the past, he worked in EY and comes with wide industry experience from telecom, retail to manufacturing to entertainment where he has handled various national and international assignments.