Rashtriya Swasthya Bima Yojana (RSBY) | Features and Benefits

The Rashtriya Swasthya Bima Yojana provides a health insurance cover to individuals or families who are below the poverty line and workers belonging to unorganised sectors. The scheme offers a sum insured of Rs.30,000 on a floater basis.
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The Rashtriya Swasthya Bima Yojana (RSBY) is a scheme by the Central Government that provides social security to the underprivileged sections of society. This is done through health insurance coverage for families that are below the poverty line (BPL). The scheme provides financial protection against any financial liabilities that may arise as a result of expenditure related to healthcare, such as planned or emergency hospitalizations. Thus, families are ensured that their healthcare is taken care of without being compromised due to financial challenges while also not being financially blindsided due to healthcare expenses. 

Features and Benefits of RSBY for Beneficiaries 

The RSBY has several features which benefit the economically challenged such as: 

  • A total sum insured of Rs.30,000 per family per annum 
  • No payment for any treatment up to Rs.30,000 has to be paid by the beneficiary to the hospital 
  • The sum insured is on a family floater basis 
  • Premiums are paid by the government 
  • Nominal fee of Rs.30 for registration or renewal 
  • There is no waiting period 
  • A limited number of exclusions 
  • Hospitalisation expenses are included 
  • Coverage is provided for all pre-existing diseases 
  • The unorganised sector is covered 
  • A family unit of five members is covered 
  • Cashless service for all the ailments covered 
  • Transportation costs are covered up to Rs.1,000 (maximum per visit is Rs.100) 
  • Extensive list of both public and private hospitals that are empaneled with the program 
  • The scheme is portable with beneficiaries being eligible to use any empaneled hospital in any state which is of benefit to migrant workers 
  • Beneficiaries can choose any hospital from the empaneled list 
  • There is no age limit to be added as a beneficiary 

Beneficiaries are also eligible for other inpatient insurance benefits as designed by their respective state governments. 

Features and Benefits of RSBY for Stakeholders 

The stakeholders in the RSBY are the insurers, hospitals, intermediaries such as NGOs and Microfinance Institutions (MFIs), as well as the state and central government. These stakeholders also have significant benefits such as: 

  • Premiums are paid to the insurer for each household enrolled 
  • Hospitals are paid for each beneficiary treated 
  • Hospitals can send online claims to the insurer and avoid extensive paperwork 
  • Hospitals get paid electronically from the insurer ensuring faster and smoother clearance of payments 
  • Money from the insurer is credited directly to the hospitals 
  • Intermediaries are also paid for the services rendered in promoting the scheme 
  • Functioning of public health care providers will be improved due to increased competition between the public and private sector hospitals 
  • The government is able to provide healthcare coverage for the Below Poverty Line demographic without missing out on anyone 
  • Increased reach, exposure, and enrolment due to the coordinated efforts of all the stakeholders 
  • IT service providers are also enlisted for the biometric-enabled smart card as well as for connecting empaneled hospitals to the government server at the district level 
  • Periodic analytical reports are generated that can help improve the scheme 

Eligibility Criteria 

The eligibility criteria for the RSBY is as given below: 

  • Workers in the unorganised sector 
  • Families that are below the poverty line 
  • Family members in a family unit of five who meet the above criteria 

Inclusions under the RSBY 

The following expenses are covered under the RSBY: 

  • Pre-hospitalisation: Any diagnostic tests done up to one day before hospitalisation 
  • Post-hospitalisation: Expenses related to the surgery or illness will be covered for up to 5 days after the date of discharge 
  • Hospitalisation: The following are covered: 
    1. Anesthetist’s fee  
    2. Anaesthesia  
    3. Bed charges (General Ward)  
    4. Blood  
    5. Boarding Charges 
    6. Consultation fee  
    7. Doctor visits  
    8. Expenses related to the use of Surgical Appliances  
    9. Food for the patient  
    10. Implants  
    11. Medicines 
    12. Nursing 
    13. OT Charges  
    14. Oxygen 
    15. Prosthetic Devices 
    16. Surgeons charges  
    17. X-Ray and Diagnostic Test 
  • Daycare treatments: Any procedure covered by the insurance company 
  • Maternity benefits: Natural childbirth, Cesarean, and any complications before either are covered. A claim of up to Rs.4,500 for Cesarean and up to Rs.2,500 for natural delivery can be made by the policyholder.  
  • Medical termination of pregnancy: Costs will be covered if the procedure is required to save the mother’s life or if caused due to an accident 
  • Newborns: Even if the number of beneficiaries has been exceeded in the family unit, newborns are automatically added as a beneficiary. This will be valid till the policy ends. After that, the baby will continue to be a beneficiary only if chosen by the policyholder at the time of renewal of the policy. 

Exclusions 

The following are the expenses not included in the scheme: 

  • AYUSH treatments 
  • Congenital external diseases  
  • Vitamins or tonics unless prescribed as treatment by a certified medical practitioner 
  • Dental treatments that are cosmetic or corrective in nature 
  • Fertility, sub-fertility or assisted conception procedures  
  • HIV/AIDS  
  • Hormone replacement therapy  
  • Illnesses arising out of substance abuse 
  • Physical changes for resembling the opposite sex 
  • Plastic or cosmetic surgery unless required due to accidents or as a part of a disease 
  • Suicide 
  • Vaccinations 
  • War 
  • Treatments availed at a convalescent home/hospital or nature care clinic 
  • Maternity: Voluntary termination of pregnancy, prenatal expenses, and hospitalisation after 48 hours of delivery or related operations  

Smart Card 

Beneficiaries are issued a biometric-enabled smart card for identification purposes. The smart card has the following uses: 

  • Identification of beneficiaries through photograph and fingerprints 
  • Information related to the patient 
  • Enables cashless transactions at empanelled hospitals 
  • Ensures portability of benefits of the scheme across empanelled hospitals anywhere in the country 
  • In case the biometric information fails to authenticate, the photograph of the head of the family is used for identification purposes 
  • Ensures that the scheme is safe and tamper-proof as only the beneficiary can use the smartcard 
  • Provides accountability for the scheme 
  • The smart card can be split in the case of migrant workers so that each can carry a share of the coverage with them separately 

The smart card is provided to the beneficiary at the enrolment station as soon as the application process is completed and details verified. 

Enrolment Process 

The RSBY has a very simple and streamlined process for enrolment which is as follows: 

  • The insurer is provided with an electronic list of eligible BPL households 
  • The insurance company prepares an enrolment schedule along with dates with the help of the officials at the district level 
  • The location and date of the enrolment is publicised 
  • The BPL list is put up at the enrolment station, which are usually the public schools in the village 
  • Each enrolment station is equipped with the required machinery to collect biometric information, photographs, and printouts 
  • When the fee of Rs.30 has been paid by the beneficiary, the smart card (in a plastic cover for protection) and an information booklet with the names of the empaneled hospitals, details of the scheme, and the helpline number is handed over to the beneficiary 
  • The smart card is authenticated by a government official on the spot 

Funding Pattern 

The funding pattern for the RSBY is as given below: 

  • State governments: 25% of the annual premium as well as any additional premium and administrative and related costs 
  • Central government: 75% of the estimated annual premium of Rs.750 subject to a maximum amount of Rs.575 per family per annum along with cost of the smart card 
  • Beneficiary: Rs.30 per annum for registration or renewal 

Current status of RSBY 

The RSBY started enrolling beneficiaries on 1 April, 2008.  As of February 2014, 36 million families across 25 states in India have been enrolled in the scheme. By March 2011, it had enrolled 10% of the Indian population, out of which 37.2% is in the BPL category. 

While the scheme was started under the Ministry of Labor and Employment, it is now under the Ministry of Health and Family Welfare. 

FAQS Related to Rashtriya Swasthya Bima Yojana (RSBY)  

  1. Whose biometric information is to be given for the smart card? 
  2. Any member of the family can give their biometric information for the smartcard. 

  3. Where are the enrollment forms for the BSBY available? 
  4. The forms will be available at the enrollment centre or can be downloaded from the state government’s website. 

  5. Can the family member list be modified in the middle of a policy period? 
  6. Family members can only be added or removed in the middle of a policy period only if there has been a death of one of the beneficiaries or birth in the family. 

  7. Should the head of the household be present at the hospital when another family member is admitted? 
  8. No, it is not necessary to have the head of the household present at the hospital. 

  9. Is there any age limit for children to be added to the RSBY beneficiary list? 
  10. No, there is no age limit for children to be added to the list. 

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