Approximately 93% of the country's workforce operates in the unorganised sector, with only a small portion covered by existing social security initiatives. Most workers lack any form of social security, with medical expenses posing significant challenges. Implementing health insurance, particularly in rural areas, presents logistical challenges. In response, the Central Government has introduced RSBY. The full form of RSBY is Rashtriya Swasthya Bima Yojana and it aims to address this pressing need for social security among unorganised sector workers.
What is the Rashtriya Swasthya Bima Yojana (RSBY)?
Before knowing about the scheme and its objectives, first understand what is RSBY. The full form of RSBY is Rashtriya Swasthya Bima Yojana. The Ministry of Labour and Employment, Government of India launched the Rashtriya Swasthya Bima Yojana (RSBY) to offer health insurance coverage to Below Poverty Line (BPL) families. RSBY's primary goal is to safeguard BPL households from the economic burdens associated with hospitalisation due to health emergencies. In this article, we will discuss the benefits, coverage, inclusions, and exclusions of RSBY.
Benefits of RSBY
The recipient will qualify for in-patient health insurance benefits as determined by the respective State Governments, tailored to the needs of the population/geographical region. However, State Governments are encouraged to include at least the following minimum benefits in the package/scheme:
- Coverage for the unorganised sector worker and their family (comprising up to five members).
- A total sum insured of Rs. 30,000 per family per year on a family floater basis.
- Cashless access to medical treatment for all covered conditions.
- Hospitalisation expenses, covering most common illnesses with minimal exclusions.
- Inclusion of all pre-existing conditions in the coverage.
- Reimbursement for transportation costs (actual expenses with a maximum limit of Rs. 100 per visit) within an overall limit of Rs. 1,000.
Read more : Government health schemes in India
Features of Rashtriya Swasthya Bima Suraksha (RSBY)
Given below are the unique benefits of Rashtriya Swasthya Bima Yojana (RSBY):
- Empowering the beneficiary:
RSBY allows BPL households to choose between public and private hospitals, making them attractive clients for hospitals due to potential revenues. - Business model for all stakeholders:
Designed as a business model with incentives for each stakeholder, facilitating scheme expansion and long-term sustainability. - Insurers:
Insurers are paid premiums for each enrolled household, motivating them to enroll more BPL households for better coverage. - Hospitals:
Hospitals receive payment per beneficiary treated, incentivizing treatment of more beneficiaries, including public hospitals which receive funds directly. - Intermediaries:
Inclusion of NGOs and MFIs aids in reaching BPL households, with intermediaries compensated for their services. - Government:
With a maximum annual payment of Rs. 750 per family, the government provides quality healthcare access to BPL populations, fostering competition and improving public healthcare providers' performance. - Information Technology (IT) intensive:
Biometric-enabled smart cards ensure smooth data flow and IT-enabled hospitals facilitate service utilisation tracking. - Security:
Biometric-enabled smart cards and key management systems ensure safety and accountability, with only the rightful beneficiary able to use the card. - Portability:
Beneficiaries can use their smart cards in any RSBY empanelled hospital nationwide, facilitating access for migrant families. - Cashless and paperless transactions:
Beneficiaries enjoy cashless benefits with smart cards and fingerprint verification, while providers submit online claims for electronic payment, making it a paperless process. - Robust monitoring and evaluation:
RSBY implements a comprehensive monitoring and evaluation system, tracking transactions nationwide and providing analytical reports for scheme improvement and competition among insurers.
Eligibility criteria for the scheme
Unorganised sector workers and their family members, who belong to the Below Poverty Line (BPL) category. Maximum 5 people from a family are covered.
Implementing agencies are tasked with verifying the eligibility of unorganised sector workers and their family members who are intended to benefit from the scheme. Smart cards will be issued to beneficiaries for identification purposes.
How to apply for Rashtriya Swasthya Bima Yojana?
The below given process is followed for enrolment under Rashtriya Swasthya Bima Yojana (RSBY):
- Step 1: The insurer receives an electronic list of eligible Below Poverty Line (BPL) households in a specified data format.
- Step 2: The insurance company collaborates with district-level officials to establish an enrollment schedule for each village, including dates.
- Step 3: Before enrollment begins, the BPL list is displayed in each village at designated enrollment stations and prominent locations. The date and location of enrollment are also announced in advance.
- Step 4: Mobile enrollment stations are established at local centers, such as public schools, in each village.
- Step 5: These stations are equipped by the insurer with necessary hardware, including devices for collecting biometric data (fingerprints) and photographs of household members, as well as a printer for smart card production.
- Step 6: Upon payment of the Rs. 30 fee and authentication by the relevant government officer, eligible beneficiaries receive their smart card instantly along with an informational pamphlet detailing the scheme and a list of hospitals.
- Step 7: The entire process typically takes less than ten minutes, ensuring efficiency.
- Step 8: Smart cards are provided in a plastic protection cover.
Also read: Pradhan Mantri Suraksha Bima Yojana
What is covered under Rashtriya Swasthya Bima Yojana (RSBY)?
Given below are the exclusions under the Rashtriya Swasthya Bima Yojana (RSBY):
- Hospitalisation expenses: Coverage extends to hospitalisation expenses for treatment of diseases or accidents. Includes nursing, boarding charges, surgeon and anesthetist fees, medications, diagnostic tests, and more. Treatment must be administered by qualified medical professionals at recognised healthcare facilities.
- Pre-hospitalisation: Covers diagnostic tests and medications up to one day before hospital admission.
- Post-hospitalisation: Expenses related to the ailment/surgery are covered for five days after discharge.
- Transportation expenses: Reimburses up to Rs. 100 per visit for transportation costs, with an annual limit of Rs. 1,000.
- Dental treatment: Dental treatments necessitated by accidents are covered.
- Daycare treatments: Covers outpatient surgical procedures not requiring prolonged hospitalisation. Includes various surgeries, chemotherapy, and follow-up care.
- Maternity benefit: Both natural and caesarean deliveries are covered. Policyholder can claim Rs. 2,500 for natural and Rs. 4,500 for caesarean deliveries. Complications before delivery and termination of pregnancy due to accidents are covered.
- Newborn coverage: Automatically includes newborns in the policy. Coverage remains valid until the end of the policy period. Policyholder can decide whether to include the baby in the policy at renewal.
What is not covered under Rashtriya Swasthya Bima Yojana (RSBY)?
- Hospitalisations not covered by the scheme are excluded from coverage.
- Vitamins or tonics not prescribed by a certified medical practitioner are not covered.
- Cosmetic dental treatments, root canals, and cavity fillings are excluded.
- Congenital external diseases are not covered.
- Illnesses resulting from substance abuse are excluded.
- Fertility treatments, gender-related procedures, and hormone replacement therapy are not covered.
- Plastic surgeries are excluded unless due to accidents or diseases.
- Vaccinations, HIV/AIDS treatment, and injuries from war or nuclear materials are not covered.
- AYUSH treatments and convalescent care are also excluded from coverage.
Also, read: Ladli Bhena Yojana
How is the Rashtriya Swasthya Bima Yojana funded?
Government of India contributes 75% of the estimated annual premium of Rs. 750 per family, capped at Rs. 565 annually, and covers the cost of the smart card. State governments contribute the remaining 25% of the annual premium plus any additional costs. Beneficiaries pay Rs. 30 annually for registration or renewal. Administrative expenses for managing the scheme are covered by the respective State Governments.
What is the smart card issued under RSBY?
The smart card serves multiple purposes, including beneficiary identification through photographs and fingerprints, as well as storing patient information. Its primary function is facilitating cashless transactions at empanelled hospitals and ensuring benefit portability nationwide. Upon authentication, the smart card is issued to the beneficiary at the enrollment station. In case biometric data fails, the photograph of the head of the family on the RSBY card can be used for identification purposes.
Claim under Rashtriya Swasthya Bima Yojana
Cashless claims are predominant under RSBY. Beneficiaries must present their Smart card at an RSBY empanelled hospital. Only these hospitals can facilitate cashless settlements. Upon verification, the hospital sends required details to the Third Party Administrator (TPA) or insurer for claim processing. Settlement occurs directly between the hospital and the TPA/insurer, eliminating the need for paperwork during claim settlement.
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Benefits of health insurance for all
Health insurance plays a crucial role in safeguarding individuals and families from the financial burden of medical expenses. Its significance can be understood through the following points:
- Financial protection:
Health insurance provides a safety net against unexpected healthcare costs, ensuring that individuals are not burdened with exorbitant bills during times of illness or injury. - Access to healthcare:
With health insurance coverage, individuals have access to a wide range of medical services, including preventive care, consultations, diagnostic tests, surgeries, and hospitalisations, without worrying about affordability. - Quality healthcare:
Health insurance often allows individuals to seek treatment from reputed healthcare providers, ensuring access to quality medical care. - Risk management:
Health insurance spreads the financial risk of healthcare expenses across a large pool of insured individuals, thereby protecting against catastrophic financial losses due to medical emergencies.
In summary, insurance is not just about financial protection but also about ensuring access to quality healthcare, peace of mind, and effective risk management in the face of medical uncertainties.
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