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 safeguards the financial and medical needs of the below poverty line (BPL) families in India.
To offer financial security against exorbitant medical expenses
To provide quality healthcare services to the BPL citizens of India
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 in India.
In this section, we have discussed everything you need to know about Rashtriya Swasthya Bima Yojana. Let us begin by understanding its features.
The RSBY scheme offers more than just basic health coverage. The policy has other salient features, such as:
Eligible beneficiaries can use the RSBY card across a wide range of network hospitals in India. Moreover, they have the freedom to select between public/government hospitals or empanelled private hospitals for treatment.
Under the RSBY scheme, beneficiaries do not have to worry about the reimbursement claim process. On obtaining the RSBY card, they can avail the cashless benefit across any network hospital empanelled under the scheme.
Eligible RSBY beneficiaries can enrol in the scheme for a nominal price of ₹30. These are the registration charges for the Rashtriya Swasthya Bima Yojana scheme. However, the annual premium amount is ₹750 per family that is paid jointly by the Central government and respective state governments.
RSBY uses robust monitoring and evaluation technology present on the smart card. The smart cards provided to the beneficiaries entail biometric information of the respective insured and is connected to the servers at the local level. 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. The insurer collects the relevant paperwork online. Additionally, the payment is made by the insurer electronically.
The working of the RSBY scheme is explained in two steps below:
The eligible beneficiaries have to pay a nominal registration fee of ₹30 as the remaining is borne by the government. Later, an insurer is selected by the respective state government based on competitive bidding.
Next, the state government appoints a State Nodal Agency (SNA). The SNA is liable to implement, monitor, and part-finance the beneficiaries enrolled in the RSBY scheme. Moreover, the SNA has to coordinate with the insurer, empanelled hospitals, district authorities, and other local stakeholders for seamless processing of the scheme.
Know that once the beneficiary is enrolled under RSBY, he/she can avail the features and benefits of the policy across listed network hospitals.
The RSBY scheme offers the following coverage.
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.
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.
Beneficiaries can claim up to ₹100 per visit under transportation expenses. The cap amount for this is ₹1,000 annually.
The scheme covers any dental treatment needed as a result of an accident.
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
Identified surgeries under general anaesthesia
Laparoscopic therapeutic surgeries allowed under daycare
Minor reconstructive procedures of limbs
Surgery of urinary system
Treatment of fractures/dislocation
Screening and follow-up care that includes medicine expense with/without diagnostic tests
Any procedure covered by the insurer
Another highlighting coverage of RSBY are 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.
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)
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
Expenses arising due to voluntary termination of pregnancy
The benefits of Rashtriya Swasthya Bima Yojana are unique and quite popular. These include:
Eligible beneficiaries can claim up to ₹30,000 for several expenses covered under the scheme.
Along with the main beneficiary, RSBY coverage is extended to his/her family members as well. The scheme covers the head of the family, spouse, and three dependent children. Moreover, 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 particular diseases. The waiting period clause is eliminated from the RSBY scheme.
Usually, health insurance plans have a waiting period of two-four years before the policy starts covering pre-existing diseases. The RSBY scheme covers all diseases irrespective of the age of the beneficiaries from day one of the policy coverage.
The RSBY smart card is issued to eligible beneficiaries at the time of enrolment. This card holds essential details of the beneficiary, such as biometrics and medical history. Once the enrollment and registration process under RSBY is successful, the beneficiaries will receive their RSBY smart card.
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.
Over five members of any family can avail the benefits of the RSBY scheme. Moreover, at least one-third of the entire Indian population is eligible to apply for the scheme.
The RSBY scheme is open for all citizens who are eligible members.
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.
The process for RSBY claim settlement is as follows:
After seeking 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 to 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.
Eligible beneficiaries can download the RSBY application form from their respective state government website.
No, RSBY does not have an age limit for enrolling dependent children.
The head of the family has to pay a nominal amount of ₹30 at the time of registration/renewal of the scheme. The remaining premium of ₹750 is paid by the Central and state governments.
Individuals belonging to the below poverty line (BPL) category are eligible to register under RSBY.
No. The presence of the family head is not necessary at the empanelled hospital when seeking medical treatment.