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Rashtriya Swasthya Bima Yojana: Eligibility, Coverage, Benefits

Read the following blog to learn everything about Rashtriya Swasthya Bima Yojana, including eligibility details, coverage, and benefits.

  • 6,544 Views | Updated on: Jun 05, 2024

Growing concerns have been raised throughout time over India’s escalating healthcare costs. Even economically secure families have struggled to meet the soaring lifestyle expenses and cover medical costs. The situation for people from lower-class and middle-class families is significantly worse. To overcome this issue Government of India has been constantly working to implement various health policies that can benefit weaker sections of society. Rashtriya Swasthya Bima Yojana (RSBY) is also a government-sponsored health insurance scheme that provides subsidized health care to economically weaker families in India. The scheme was launched in 2012 and is currently available in all states and union territories.

The Rashtriya Swasthya Bima Yojana (RSBY) was introduced in 2008 by the Ministry of Labour and Employment, Government of India, to offer dependable financial assistance to cover the costs of necessary medical care. Currently, the Ministry of Health and Family Welfare, Government of India, is in charge of the program. The RSBY scheme aims explicitly to offer affordable healthcare services and social security to lower-income families incapable of fully covering their medical expenses.

What is Rashtriya Swasthya Bima Yojana?

The Central Government’s RSBY program offers social security to the less fortunate segments of society. This is accomplished through providing low-income families with health insurance (BPL). The program offers protection from any financial obligations that can develop as a result of healthcare-related expenses, such as planned or unplanned hospital stays. Families are thus protected from having their healthcare impaired owing to financial difficulties and are also protected from being financially unprepared for medical bills.

The program protects people or families below the poverty line (BPL), notably those who work in organized sectors and cannot afford medical bills. The program covers all financial liabilities from healthcare expenditures, such as emergency hospitalization. It offers a reasonable sum insured of ₹30,000 on a floater basis.

How Does Rashtriya Swasthya Bima Yojana (RSBY) Work?

The RSBY works by providing free (or subsidized) health care to poor families in India. Beneficiaries of the scheme can avail of free health care at empaneled hospitals and clinics. The scheme covers a variety of healthcare services, including hospitalization, surgery, medicines, and diagnostics. The scheme is funded by the centra l and state governments and is administered by the Ministry of Health and Family Welfare.

RSBY is a major step towards ensuring access to quality healthcare for India’s poor and marginalized sections of society. The scheme has helped to reduce out-of-pocket expenses for medical care and has improved access to healthcare for millions of people.

What is Covered in the RSBY Scheme?

The world’s most extensive and 100% state-sponsored health assurance plan, Rashtriya Swasthya Bima Yojana provides health insurance coverage to individuals for:

Hospitalization Expenses

RSBY covers expenses related to hospitalization concerning treating a disease, illness, or accident. The benefit is available for the family of the insured as well. However, only costs incurred by a licensed physician or another medical professional at an authorized nursing home or hospital are taken into account. The following hospitalization costs are specifically covered by RSBY:

  • Surgery
  • Bed and lodging (general ward)
  • Nursing and boarding
  • Anesthesia
  • Consultation
  • Doctor visits
  • Blood, oxygen, etc.
  • All operation theatre expenses
  • Medicines
  • Supporting devices like prosthetics
  • X-Ray and other diagnostic tests
  • Food (only for the patient)
  • Implants
  • Surgical appliances costs

Pre-Hospitalization Costs

This scheme covers any pre-hospitalization charges like diagnostic tests, medicines, imaging tests, etc., performed or issued a day before the patient’s admission to the hospital.

Post-Hospitalization Costs

The scheme pays for the five-day post-treatment recovery cost of an ailment/surgery for which the patient was primarily hospitalized.

  • Transportation Charges

The insured is given ₹100 per visit as transportation coverage, up to a maximum of ₹1,000.

  • Dental Treatment

Any dental treatment expenses incurred because of an accident are covered in the RSBY.

  • Daycare Charges

All daycare or outpatient charges are a part of the RSBY scheme. Some of the daycare costs included are:

  • Ear or eye surgery
  • Dental surgery due to an accident
  • Haemodialysis
  • Nose surgery
  • Parenteral chemotherapy
  • Gastrointestinal surgery
  • Prostate surgery
  • Throat surgery
  • Radiotherapy
  • Fractures/dislocation

Maternity Benefit

The insurance cover extends to all types of birth deliveries. The cover offers ₹2,500 for standard delivery, whereas, for cesarean birth delivery, the policyholder gets coverage of ₹4,500. Pre-delivery complications are also included. Further, involuntary termination of pregnancy because of an accident, etc., is also funded by RSBY.

Newborn Coverage

Even if the maximum number of beneficiaries has been reached, the insurance automatically covers a newborn born within the policy term. The cover continues till the end of the policy period, and the decision for renewal depends on the policyholder.

How is RSBY Financed?

In the majority, the Central Government sponsors (75%) of the Rashtriya Swasthya Bima Yojana. The rest of the premiums (25%) are paid by the government of the respective states. In addition, the policyholder pays ₹30 per annum for registration or renewal. This helps the government cover the administrative costs involved in the scheme. However, for the North-Eastern States and Jammu & Kashmir, the Central Government sponsors 90% of the RSBY scheme, and the state funds the rest of the insurance plan.

What is Not a Part of RSBY?

As its primary purpose, the Rashtriya Swasthya Bima Yojana provides health insurance coverage to the underprivileged. Hence, the policy excludes the following:

  • All AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homoeopathy) treatments
  • Congenital health issues
  • Vitamins or tonics
  • Cosmetic or corrective dental treatments
  • HIV/AIDS
  • Suicide
  • War
  • Vaccines
  • Voluntary termination of pregnancy
  • Prenatal expenses
  • Hospitalization costs after 48 hours of delivery or any related operation
  • Plastic or cosmetic surgery of any body part, unless required because of a disease
  • Sex change operations
  • Hormone replacement surgery
  • Fertility or related procedures
  • Accidents, diseases, or conditions arising due to substance abuse
  • Treatment at an unauthorized or registered nursing home or hospital

What is the Eligibility Criterion for RSBY?

The Rashtriya Swasthya Bima Yojana is available only for people who fall under any of these categories:

  • Workers or employees in the unorganized sectors
  • Families or individuals living below the poverty line. The State government must issue the list. The RSBY scheme has no upper limit. All members of the BPL household can be a part of this scheme.
  • Registered members of the welfare boards

Enrolment Registration Procedure of Rashtriya Swasthya Bima Yojana (RSBY)

To apply for the RSBY, you need to submit the following documents to the nearest RSBY enrollment center:

  • Aadhaar card
  • Ration card
  • Income certificate
  • BPL card
  • Proof of residence

The enrollment process is free of charge. The center will verify your documents and issue you an RSBY smart card. Once you are enrolled in the scheme, you can use your RSBY smart card to avail free medical care at empaneled hospitals and clinics.

What are the Features of the RSBY Scheme?

The RSBY scheme has excellent features that aim to benefit the economically underprivileged class significantly. Some of these Rashtriya Swasthya Bima Yojana features include:

  • A comprehensive sum insured of ₹30,000 for the family on a floater basis
  • Cashless treatment facility up to ₹30,000 at the authorized hospital or nursing home.
  • All premiums are paid by the central government.
  • Easy registration and renewal of the policy. The policyholder pays only ₹30 for registration or renewal.
  • No waiting period for the inclusion of any defined benefits.
  • Comprehensive medical coverage with limited exclusions.
  • The benefit is extended to all pre-existing disease. This applies even if the policyholder knew about the illness while buying the insurance.
  • Only family units of five members are eligible for insurance coverage.
  • Extensive hospital network in both public and private sectors that offers cashless treatment.
  • Transportation costs you to ₹1,000.
  • Portability of the scheme. This permits the policyholder to enroll at any panel hospital, irrespective of the state.
  • Robust monitoring and evaluation using IT-enabled software and the smart card’s chips. These highly secure smart cards keep track of all transactions and store the policyholder’s biometric data.

Further, the beneficiaries can also avail of other health insurance plans, public or private, to enhance their financial protection against rising medical costs.

RSBY Benefits

This program has enrolled and benefitted millions of families. Rashtriya swasthya bima yojana benefits are stated below:

Sum Insured

Up to ₹30,000 can be claimed for a variety of expenses that are protected by the policy.

Coverage For The Family

This layout is suitable for a five-person Indian family. The plan covers the family’s head, spouse, and three dependents. Until the policy’s expiration, a new baby may be added as a beneficiary.

No Waiting Period

A waiting period is when a policyholder cannot file a claim for a particular set of circumstances as determined by the insurance provider. During the waiting period, one must cover the expense of the treatment out of their own cash. However, there is no such clause in the RSBY.

Pre-Existing Diseases

As the term implies, a pre-existing disease is any illness that the policyholder or the beneficiaries had before they bought the policy. This covers any illnesses that the policyholder might not have known about at the time of policy purchase. Pre-existing conditions typically have a 2 to 4-year waiting period in health insurance policies. Nevertheless, from the date of purchase, these are protected by RSBY regardless of the beneficiary’s age.

How to Avail of the RSBY Scheme? What is RSBY Card?

The Rashtriya Swasthya Bima Yojana form is available on each state’s official website. The government has authorized specific insurance companies to roll out the RSBY scheme at the village level. BPL families or individuals can reach the enrollment centers on the date and time specified in the schedule issued by the insurance companies.

The registration process is generally 10-15 minutes long, and the policyholder gets the RSBY card. The card contains the policyholder’s biometric details and RSBY customer care details. An extensive of hospitals are available in the enrolment center.

What is the RSBY Claim Settlement Procedure?

This scheme offers cashless RSBY claim settlement to beneficiaries up to ₹30,000. The beneficiary is not liable to pay any charges to the authorized hospital up to an upper limit of ₹30,000 on a floater basis. The benefit is available on the smart card issued under the policy. No manual paperwork is required at the time of claim settlement on the part of the insured. All RSBY claims are settled electronically. The government covers the cost of treatment. And once the patient is treated, the impaneled hospital sends an electronic report to the Third-Party Administrator (TPA) appointed by the government or the insurance provider.

Post receipt of the electronic report, the insurer pays the hospital in accordance with the insurance agreement between the parties.

Conclusion

Rashtriya Swasthya Bima Yojana is a unique and cost-effective insurance plan aiming to provide affordable healthcare facilities for those below the economically deprived. Kotak Life values progressive initiatives like RSBY and endeavors to increase insurance penetration in the country by offering highly economical and affordable health insurance plans for all Indian citizens. Together India can be healthy and prosperous.

Key Takeaways

  • Rashtriya Swasthya Bima Yojana (RSBY) provides complimentary or subsidized health care to families below the poverty line in India.
  • The scheme is currently available in all states and union territories.
  • It covers different medical care services, including hospitalization, surgery, medicines, and diagnostics.
  • The scheme is sponsored by the central and state governments and is administered by the Ministry of Health and Family Welfare.

FAQs

1

Is the RSBY policy still valid?

Yes, you can still avail of the benefits of RSBY, however, it is now known as Ayushman Bharat Yojana.

2

How do I check my RSBY card validity?

All you have to do is to login into the official website RSBY, select your ‘State’ under “Scheme Status, and Click “Submit” after entering the RSBY scheme in the portal. Your screen will show the RSBY scheme status.

3

Can I avail of RSBY benefits if I am not below the poverty line but have a low income?

Unfortunately, you cannot benefit from RSBY if you are above the poverty line. Only the family that adheres to the RSBY’s eligibility requirements is permitted to enroll in the program.

4

Is there any age limit to avail of the benefits of RSBY?

No, there is no maximum age limit for availing of the benefits of the RSBY scheme.

- A Consumer Education Initiative series by Kotak Life

Amit Raje
Written By :
Amit Raje

Amit Raje is an experienced marketer who has worked in various Fintechs and leading Financial companies in India. With focused experience in Digital, Amit has pioneered multiple digital commerce in India. Now, close to two decades later, he is the vice president and head of the D2C business department. He masters the skill of strategic management, also being certified in it from IIMA. He has challenged his challenges and contributed his efforts in this journey of digital transformation.

Amit Raje
Reviewed By :
Prasad Pimple

Prasad Pimple has a decade-long experience in the Life insurance sector and as EVP, Kotak Life heads Digital Business. He is responsible for developing user friendly product journeys, creating consumer awareness and helping consumers in identifying need for life insurance solutions. He has 20+ years of experience in creating and building business verticals across Insurance, Telecom and Banking sectors

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