What Is Rashtriya Swasthya Bima Yojana?

RSBY or National Health Insurance Programme is a government-sponsored scheme for Indian citizens that belong to the low-income strata or Below Poverty Line (BPL). The full form of RSBY is Rashtriya Swasthya Bima Yojana. This scheme can be categorised as a family floater health insurance plan where the policyholder and his/her family can avail benefits under the programme.

What Is Covered Under RSBY?

The Rashtriya Swasthya Bima Yojana is an unusual health insurance policy that provides extra benefits as compared to a commercial plan. Here are the coverages of RSBY insurance:

1. Hospitalization Expenses:

Expenses related to hospitalization for the treatment for a disease, illness, or an accident will be covered under the RSBY. This coverage will be extended to the policyholder’s family as well. However, the treatment and hospitalization shall be taken at a Nursing Home/Hospital by a qualified Physician/Medical Specialist/Medical Practitioner. The expenses related to the following (but not limited to) will be covered by the insurance company:

  • Nursing & Boarding Charges
  • Bed charges (General Ward)
  • Surgeons charges
  • Anesthetists
  • Doctor visits
  • Consultation fee
  • Anaesthesia
  • Blood
  • Oxygen
  • OT Charges
  • Expenses related to the use of Surgical Appliances
  • Medicines
  • Prosthetic Devices
  • Implants
  • X-Ray and Diagnostic Test
  • Food (patient only)
  • Etcetera

2. Pre Hospitalization:

The scheme will cover the cost of diagnostic tests and medicines up to one day before a patient gets admitted to the hospital.

3. Post Hospitalization:

The expenses related to an ailment/surgery for which the patient was admitted will be covered for five days after the date of discharge.

4. Transportation Expenses:

The policyholder can claim a maximum of Rs.100/- per visit under transportation. The annual cap for this cost is one thousand rupees.

5. Dental Treatment:

The cost of dental treatments required as a result of an accident will be covered under the Rashtriya Swasthya Bima Yojana.

6. Daycare Treatments:

A daycare treatment is a surgical procedure that does not require prolonged hospitalization. These are also referred to as out-patient treatments. The following (not limited to) list of daycare treatments is covered under RSBY.

  • Contracture release of a tissue
  • Dental surgery following an accident
  • Ear surgery
  • Eye Surgery
  • Gastrointestinal surgeries
  • Genital surgery
  • Haemo-Dialysis
  • Hydrocele surgery
  • Identified surgeries under general anaesthesia
  • Laparoscopic therapeutic surgeries allowed under daycare
  • Lithotripsy
  • Minor reconstructive procedures of limbs
  • Nose surgery
  • Parenteral Chemotherapy
  • Prostate surgery
  • Radiotherapy
  • Surgery of urinary system
  • Throat surgery
  • Tonsillectomy
  • Treatment of fractures/dislocation
  • Screening and follow up care including medicine cost with and without diagnostic tests
  • Any procedure covered by the insurance company

7. Maternity Benefit:

Both – natural and caesarean type of deliveries are covered under this scheme. A claim for Rs. 2500 for natural and 4500 for caesarean delivery can be made by the policyholder. Any complications before delivery are also covered.

The cost of involuntary termination of pregnancy that was caused due to an accident or in a situation where saving the life of the mother is necessary, will be covered.

8. Newborn Coverage:

The new-born baby will be added automatically to the RSBY policy even if the number of beneficiaries has exceeded. This coverage will be valid until the end of the policy period. The decision of including the baby in the policy at the time of renewal, lies with the policyholder.

What Is Not Covered Under RSBY?

The Rashtriya Swasthya Bima Yojana facilitates underprivileged people to avail necessary treatment during a medical emergency. Thus, the following conditions are not covered under the plan:

  • Any claim for hospitalization that is not covered under the scheme will not be honoured
  • Cost of vitamins or tonics unless prescribed as a part of treatment by a certified medical practitioner
  • Dental treatments that are cosmetic or corrective in nature will not be covered. Also, root canal, filling of cavity, or procedures related to wear and tear are not covered.
  • Congenital external diseases
  • Substance abuse: Any illness arising out of excessive use of alcohol, drugs, or any intoxicating substance is not covered.
  • Fertility, sub-fertility or assisted conception procedures
  • Physical changes for resembling the opposite sex
  • Hormone replacement therapy
  • Plastic/cosmetic surgery unless required due to an accident or as a part of a disease
  • Vaccinations
  • Suicide
  • War, an act of a foreign enemy, invasion, or warlike operations by nuclear materials
  • Treatments availed at a convalescent hospital, health hydro, convalescent home, nature care clinic, etc as described in the policy documents. 

Exclusions Related to Maternity Benefit:

  • Prenatal expenses
  • The cost of voluntary termination of pregnancy
  • Hospitalization ended 48 hours after delivery and related operations

Features of Rashtriya Swasthya Bima Yojana:

RSBY is much more than a basic health insurance product. It is a beneficial business model as well. Here are the features of this plan:

1. Guaranteed Treatment:

Rashtriya Swasthya Bima Yojana has been created for people who are below the poverty line of India. They may not always get the required treatment for accidental injuries or illnesses. This scheme aims to eliminate such situations to a great extent.

2. Low Premium:

An eligible person can enrol in the scheme by paying Rs. 30 as registration fee for availing the coverage offered by the health insurance policy. The remaining premium amount i.e. Rs.750 per family per year will be borne jointly by the Central Government and the respective State Governments.

3. No Age Limit:

Unlike commercial health insurance policies where an entry age is specified, here an eligible person belonging to any age group can enrol under the plan.

4. Option To Choose:

The policyholder may choose to avail treatment at an RSBY empanelled hospital of his/her choice. There is no condition for availing treatment at a public hospital.

5. Beneficial For All Stakeholders:

Not only does the policyholder and the family benefit from the RSBY scheme but also everyone who is involved in providing this service to the policyholder. The scheme is designed in such a way that each stakeholder will receive incentives, including NGOs and MFIs.

6. Technology And Security Enabled:

The RSBY health insurance scheme uses robust monitoring and evaluation with the help of IT-enabled apps and chips present on the smart card. These cards have the biometric information of the policyholder and are connected to servers at the local level for faster exchange of data. Biometric information and transaction records are managed with the help of a high-security system that keeps a track and carries out frequent reporting.

RSBY Benefits:

The following benefits make the RSBY unique and popular. Millions of families have enrolled under this scheme to date. Here are the benefits of the plan:

1. Sum Insured:

One can claim up to Rs. 30000 for various expenses that are covered under the policy.

2. Coverage For The Family:

A typical Indian family of five members can benefit from this plan. The head of the family, spouse and three dependents are covered under the plan. A newborn baby can become an additional beneficiary until the expiry of the policy.

3. No Waiting Period:

A waiting period is a time when a policyholder cannot make a claim against certain conditions as specified by the insurance company. One needs to bear the cost of treatment from their own pocket during the waiting period. However, the RSBY does not have any such clause.

4. Pre-existing Diseases:

As the name suggests, a pre-existing disease is any ailment suffered by the policyholder or the beneficiaries before purchasing the policy. This includes the diseases that the policyholder may not be aware of when purchasing the policy.
Usually, in health insurance policies a waiting period of 2 to 4 years is imposed on pre-existing diseases. However, these are covered under RSBY irrespective of the age of a beneficiary from the date of purchase.

Eligibility For Rashtriya Swasthya Bima Yojana:

Only the family that fulfils the eligibility criteria of the RSBY is allowed to enrol under the scheme. Here is the eligibility required for RSBY:

  • The members of a family that are listed in the Below Poverty Line list created by the State government can enrol in this scheme
  • The applicant could be a worker at any unorganized sector
  • Registered member of the welfare boards

How To Make A Claim Under Rashtriya Swasthya Bima Yojana?

The claims made under RSBY are mostly cashless in nature. A beneficiary of this policy needs to produce the Smart card at the hospital. Note that only a hospital empanelled under RSBY can settle cashless claims. The hospital will send the necessary information to the Third Party Administrator (TPA) or to the insurance company. The claim will be settled between the hospital and the insurance company/TPA after the process of verification is complete. No paperwork is required at the time of claim settlement.