What is Rashtriya Swasthya Bima Yojana (RSBY)?

Rashtriya Swasthya Bima Yojana (RSBY)

The Government of India, over the years, has taken multiple initiatives to provide adequate healthcare infrastructure to its citizens. One such initiative introduced in 2008 is the Rashtriya Swasthya Bima Yojana (RSBY) scheme. The policy provides financial assistance to below-poverty-line families during medical emergencies.

Under the RSBY scheme, over 75% of financing is provided by the Central Government, while the rest is funded by the State Government. Ideally, the goal of the scheme is to supply optimum health coverage to economically backward families across the country. In this section, we have discussed everything you need to know about Rashtriya Swasthya Bima Yojana. So, let us begin by understanding its features.

Features and Benefits of Rashtriya Swasthya Bima Yojana for Beneficiaries

The RSBY scheme offers more than just basic health coverage and comes with multiple benefits and salient features, such as:

• Eligible beneficiaries can use the RSBY card across a wide range of network hospitals in India.

• The scheme offers the freedom to select between public/government hospitals or empanelled private hospitals for treatment.

• On obtaining the RSBY card, policyholders can avail the cashless benefit across any network hospital empanelled under the scheme.

• The annual premium amount is ₹750 per family and is paid jointly by the Central Government and respective State Governments.

• Beneficiaries’ details are secured with a high-tech system that also keeps track of and maintains RSBY-related reports.

• The RSBY scheme does not involve heavy documentation.

• Additionally, the payment is made by the insurer electronically.

• Eligible beneficiaries can claim up to ₹30,000 for several expenses covered under the scheme.

• A newborn is automatically added to the list until the policy expires.

• There is no waiting period that the beneficiaries have to complete when claiming for pre-existing diseases. RSBY also eliminates the initial waiting period clause.

Features and Benefits of Rashtriya Swasthya Bima Yojana for Stakeholders

Insurers, hospitals, intermediaries like NGOs, State, and Central Governments are deemed stakeholders of RSBY. Here’s how stakeholders can benefit from the Rashtriya Swasthya Bima Yojana:

• Premiums are paid to the insurance company for every registered household.

• Hospitals receive the payment for treating each beneficiary.

• Hospitals can dodge the extensive paperwork by sending online claims.

• Hospitals receive payments online for faster and seamless clearance of payments.

• Insurers directly credit the money to the hospitals.

• Intermediaries are paid for services offered in promoting the RSBY scheme.

• The government can make healthcare services feasible for families below the poverty line. 

Eligibility of Rashtriya Swasthya Bima Yojana

To avail the benefits and healthcare facilities under the RSBY scheme, one has to meet the eligibility criteria. It includes:

• Any individual who works in an unorganised sector is eligible to enrol for the Rashtriya Swasthya Bima Yojana policy. Additionally, those people registered under the welfare board can also register.

• The scheme is applicable for every worker under the BPL category, irrespective of their age. The RSBY has no cap on the age limit of an individual.

• Families with up to five members can avail the benefits of the RSBY scheme.

• The RSBY scheme is open for all citizens who are eligible members.

What is Covered Under Rashtriya Swasthya Bima Yojana?

The RSBY scheme offers the following coverage:

• Hospitalisation Expenses

The scheme covers eligible RSBY beneficiaries who need hospitalisation due to any illness or accident. This coverage is also extended to their family members. However, everyone eligible should avail treatment at an empanelled hospital.

• Pre- and Post-Hospitalisation Costs

RSBY also covers the cost of diagnosis and medication needed before any hospitalisation. Moreover, the scheme also covers the expenses incurred post discharge (for check-ups and other emergencies). Moreover, the patient will be covered for five days post hospitalisation.

• Transportation Expenses

Beneficiaries can claim up to ₹100 per visit under transportation expenses. The cap amount for this is ₹1,000 annually.

• Dental Treatment

The scheme covers any dental treatment needed as a result of an accident.

• Maternity and Newborn Benefits

Another highlight of RSBY is its maternity and newborn benefits. Beneficiaries can claim up to ₹2,500 for natural deliveries and ₹4,500 for C-sections. Any complication involved in the pregnancy is covered under the scheme as well. Moreover, the expenses incurred for involuntary termination of pregnancy due to an accident or to save the life of the mother are covered.

Additionally, the newborn is added to the RSBY coverage automatically after birth (even if the number of beneficiaries covered under the scheme exceeds the set limit). The coverage is valid until the policy period and the beneficiary gets to decide whether to include the baby at the time of renewal or not.

• Daycare Treatment

Surgical procedures that do not require prolonged hospitalisation are termed daycare treatments. These are also known as out-patient procedures and are covered under RSBY. The list of daycare treatments covered under the scheme are as follows:

• Contracture release of a tissue

• Dental surgery as a result of 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 that includes medicine expense with/without diagnostic tests

• Any procedure covered by the insurer

What is Not Covered Under Rashtriya Swasthya Bima Yojana?

RSBY does not cover the following things:

• Any claims raised against medical conditions that are not covered by the insurer

• Expenses related to vitamins or tonics (unless they are prescribed by the doctor)

• Cosmetic surgeries

• Root canal, filling or cavities, and general oral hygiene check-up

• Congenital external diseases

• Hospitalisation due to substance abuse

• Fertility, subfertility, or assisted conception procedures

• Hormone replacement therapy

• Vaccinations

• HIV/AIDS

• Suicide

• Expenses arising due to voluntary termination of pregnancy

Enrolment and Registration Process of Rashtriya Swasthya Bima Yojana

RSBY authorities have set up several enrolment centres across the country so that eligible beneficiaries under the scheme can register easily. If you meet the eligibility criteria mentioned above, then you must present proof for the same. Besides, if you wish to extend the coverage to your family members, provide their details and identity proofs during registration.

The eligible family has to pay ₹30 to register/renew their coverage for the RSBY scheme. Once registration/renewal is successful, each enrolled member will be issued a smart card with which they can avail the benefits under the scheme.

Enrolment centres usually have a list of local families that are eligible under the Rashtriya Swasthya Bima Yojana scheme. Because of this, they can ensure the right household is getting enrolled, further simplifying the process of enrolment and registration.

Rashtriya Swasthya Bima Yojana Claim Process

The process for RSBY claim settlement is as follows:

• After the beneficiary’s treatment at the empanelled hospital, the hospital authorities have to send an electronic report to the insurer/third party administrator (TPA).

• This entitled individual will verify the details submitted by the hospital and make the necessary settlement with the hospital directly.

• The beneficiary seeking treatment only has to present the RSBY smart card at the empanelled hospital. No other documentation is needed for claim settlement.

To Wrap it Up!

Nearly one-third of the entire Indian population can avail the benefits of the Rashtriya Swasthya Bima Yojana. However, health insurance is essential for the remaining two-thirds of the total Indian population as well. Hence, if you are not eligible for government-initiated schemes, you must opt for a health cover that offers maximum coverage at an affordable cost. Along with the aforesaid features, we at Bajaj MARKETS, also allow you to customise the healthcare plan with lucrative add-ons. So, check out our range of health insurance policies now!

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