Health Insurance

Rashtriya Swasthya Bima Yojana (RSBY) - Features, Benefits Eligibility, Coverage

Dec 03, 2021

Indian citizens belonging to the low-income strata or Below poverty line (BPL) enjoy the benefits of a government-sponsored health insurance scheme known as Rashtriya Swasthya Bima Yojana or National Health Insurance Programme. RSBY is a family floater health insurance plan, which entitles the policyholder and the members of his family to reap the benefits of the health insurance provided under this scheme by the government. 

Note: The Rashtriya Swasthya Bima Yojana can now be availed as the Ayushman Bharat Yojana which started under the able leadership of our Prime Minister Narendra Modi on behalf of the Government of India. 

Features of the Rashtriya Swasthya Bima Yojana:

  1. Guaranteed Return:
    RSBY assures guaranteed treatment for accidental injuries and illnesses for the citizens of our country who are below the poverty line.
  2. Low Premium:
    An eligible person (depending on the mentioned income level) can register for the scheme by paying a registration fee of INR 30 only. The remaining yearly premium of INR 750 per year, per family, is borne jointly by the Central Government and the respective State Governments.
  3. Age no bar:
    An eligible person of any age group can enrol under this scheme as no entry age is specified for this plan, unlike the commercial plans.
  4. Option to choose:
    The policyholder has the option to choose the empanelled hospital for availing the treatment. It is not mandatory to avail treatments from general hospitals only.
  5. Benefits for all stakeholders:
    Everyone, other than the policyholder and the family members, who are involved in providing the insurance service, benefits from this plan as they are given incentives including NGOs and MFIs.
  6. Technology and Security enabled:
    The RSBY scheme is always monitored and evaluated by various IT apps and smart card chips. The biometric information of the policyholders is available on their smart cards which are linked to the local server for swift data exchange. A high-security system is used to keep track of and manage the transaction records of a person.

Benefits of Rashtriya Swasthya Bima Yojana

RSBY with its unique features and benefits have become extremely popular and millions of families have registered themselves under this scheme to avail of the following benefits:

  1. Sum Insured: 
    This policy provides a cover of INR 30,000 for various expenses incurred.
  2. Family Cover: 
    A family of five, namely the head of the family, spouse and three dependants are covered under this plan. A newborn child is automatically covered under the plan till the time of renewal of the policy.
  3. No Waiting period: 
    The clause of the waiting period, as in the commercial plans is not valid for RSBY. 
  4. Pre – Existing Diseases:
    In Commercial health insurance plans, a waiting period of 2 to 4 years is applied in case of certain pre-existing diseases. However, there is no such term of the waiting period for RSBY.  In RSBY, a person, irrespective of the age of the beneficiary, is covered for the treatments from the date of purchase of the policy.

Eligibility for enrolment to RSBY:

Every citizen of India is not eligible to enrol under the scheme of Rashtriya Swasthya Bima Yojana. The families who fulfil the criteria of eligibility as decided by the Government of India can enrol their names for this benefit.  Eligibility criteria for RSBY is:

  • The families enlisted in the Below poverty line list created by the State Government can register themselves for RSBY.
  • A worker in any unorganised sector can be an applicant.
  • An enrolled member of the welfare boards.

Coverage under Rashtriya Swasthya Bima Yojana

RSBY or the National Health Insurance Programme is way different from the commercial plans, as it provides extra covers to its policyholders.

Let us take a look at the coverage provided by the RSBY plan.

  1. Hospitalisation Expenses: 

RSBY covers the hospitalisation expenses for the treatment of a disease or any illness or even any treatment related to an accident of the policyholder and his /her family members. A qualified/registered medical practitioner, physician or medical specialist must carry out the treatment in a hospital or nursing home. The insurance company will cover the expenses incurred under the mentioned heads. However, the health insurance cover is not  limited only to these expenses:

  • Bed charges for the general ward dormitory
  • Surgeon charges
  • Consultation fees
  • Doctor Visits
  • Anaesthetists
  • Anaesthesia
  • Nursing and Boarding charges
  • OT charges
  • Oxygen
  • Blood
  • Incurred expenses for surgical appliances
  • Prosthetic devices
  • Medicines
  • Diagnostic tests and X-Ray
  • Implants
  • Food for the patient only
  • Additional or miscellaneous expenses

 

2. Pre-Hospitalisation Expenses:

Expenses incurred for diagnostic tests along with medicines related to the hospitalisation, prior to upto day before the patient is hospitalised, is covered under the RSBY scheme.

3. Post Hospitalisation Expenses: 

Expenses for the disease or surgery due to which the patient had to be admitted to the hospital, is covered under RSBY scheme for a maximum of five consecutive days after being discharged from the hospital.

4. Transportation Expenses:

This expense has a cap of INR 1,000 in a year with a claim of a maximum INR 100 per visit as transportation.

5. Dental Treatment:

The Rashtriya Swasthya Bima Yojana covers dental treatment only in case dental treatment is required as a result of an accident.

6. Daycare Treatments:

Daycare treatments, also referred to as out-patient treatments, do not require prolonged hospitalisation. The list of daycare treatments included under the RSBY scheme is given below, for reference. However, the following list is not limited to the mentioned treatments only:

  • Surgery of the Eye
  • Surgery of the Ear
  • Dental surgery after an accident
  • Gastrointestinal surgeries
  • Hydrocele surgery
  • Haemodialysis
  • Nose surgery
  • Genital surgeries
  • Contracture release of a tissue
  • Specific Surgeries using general anaesthesia
  • Lithotripsy
  • Laparoscopic therapeutic surgeries permissible under daycare
  • Minor reconstructive surgeries of limbs
  • Parenteral chemotherapy 
  • Throat surgery
  • Radioactive therapy
  • Tonsillectomy
  • Prostate surgery
  • Surgery of the urinary system
  • Treatment of fracture or dislocation
  • Follow up treatment and care and screening including diagnostic tests and medicines
  • Any additional surgeries covered by the insurer

7. Maternity Benefits:

The Rashtriya Swasthya Bima Yojana covers maternity insurance expenses for both Normal and Caesarean modes of delivery. The maximum limit of a claim for the natural mode of delivery is INR 2,500 and for the caesarean mode of delivery, it is capped at INR 4,000. All complications before delivery are covered under the RSBY scheme.

In case of an accidental or emergency termination of any pregnancy, the cost is borne by the insurance company in order to save the life of the mother. 

8. Newborn Coverage

A newborn baby born to parents under the RSBY scheme is automatically included in the scheme, even if the maximum number of included family members have exceeded. In this plan, the coverage is enjoyed by the newborn child till the valid period of the policy. During the renewal of the policy, the parents need to take a call on whether they want to include the child in the renewed policy.

Issues not covered under the purview of RSBY:

The Indian citizens under the below poverty line category can avail of the Rashtriya Swasthya Bima Yojana and facilitate their necessary medical treatments during an emergency. Hence, it is also important to keep in mind the issues that are not covered under this scheme. 

They are as follows:

  • Suicide
  • HIV/AIDS
  • Vaccinations
  • Hormone Replacement Therapies
  • Sex change procedures
  • Plastic or cosmetic surgeries unless they are required following an accident or an illness
  • Fertility related surgeries or artificial conception procedures
  • Expenses for tonics or vitamins not prescribed by a registered medical practitioner
  • Cosmetic or corrective dental surgeries. Root canal therapy, filling of the tooth cavity, etc are not covered under RSBY.
  • Treatments for ailments owing to an overdose of drugs, alcohol or any other intoxicating substance are excluded
  • External congenital diseases
  • AYUSH
  • War, warlike operations, invasion, etc are not covered under RSBY
  • Other treatments received from convalescent homes or hospitals, health hydro, nature care, etc as mentioned in the policy are not covered
  • Any other claim not mentioned in the policy document will not be allowed for a claim
  • Maternity exclusions
  • All expenses related to the voluntary termination of pregnancies
  • Prenatal expenses
  • Hospitalisation expenses post 48 hours post-delivery and any related procedure

Conclusion

This Government health insurance scheme is truly beneficial for the people of the low-income group who can barely manage to earn for their existence. The RSBY helps them to at least get a basic level of medical treatments during an emergency.

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