Rashtriya Swasthya Bima Yojana

Launch of the Rashtriya Swasthya Bima Yojana scheme

The Rashtriya Swasthya Bima Yojana was launched on 1st April, 2008 by the Ministry of Labour and Employment which is a ministry under the Government of India.

What is the Rashtriya Swasthya Bima Yojana scheme all about?

The Rashtriya Swasthya Bima Yojana scheme provides health insurance coverage to families Below Poverty Line (BPL) categories. It also includes labourers and workers in the unorganised sector which constitute about 93% of the total workforce of India. The scheme pays for the medical expenses incurred by the covered members so that they can avail quality healthcare easily without having to spend huge amounts of money on illnesses and injuries.

Eligibility under the Rashtriya Swasthya Bima Yojana scheme?

Rashtriya Swasthya Bima Yojana covers the following categories of individuals –

• Workers of the unorganized sector who also belong to BPL families.
• The family members of the workers can also be covered under the scheme. However, a maximum of 5 family members per family can be covered. The members should be the worker, spouse and up to three dependent children.

Examples of workers who are eligible to be covered under the scheme include the following –

• MNREGA workers who have worked for more than 15 days in the last financial year
• Sanitation workers
• Domestic help and workers
• Mine workers and miners
• Rickshaw pullers, auto drivers and taxi drivers
• Railway porters
• Street vendors
• Construction workers and building workers who are registered with Welfare Boards
• Beedi workers
• Rag pickers, etc.

What is covered under the Rashtriya Swasthya Bima Yojana scheme?

The Rashtriya Swasthya Bima Yojana covers the following types of healthcare expenses –

• Hospitalisation expenses of the insured and his family members on a floater basis
• The maximum coverage allowed under the scheme is up to INR 30,000
• Hospitalisation expenses incurred for defined diseases (mentioned in the scope of the scheme)
• Transport expenses incurred after being discharged from the hospital. The limit on coverage of these expenses is INR 100 per instance of hospitalisation up to a maximum limit of INR 1000 per coverage year per family
• Pre-existing illnesses are also covered from the first day of coverage under the scheme

How is the Rashtriya Swasthya Bima Yojana scheme funded?

Since Rashtriya Swasthya Bima Yojana is a Government sponsored health insurance scheme, the Government of India bears 70% of the cost of the scheme and the remaining 30% is borne by the State Government. In case of North-eastern States and Jammu and Kashmir, the Government of India bears 90% of the cost and the State Governments bear 10%. The beneficiaries who are covered by the scheme have to pay only INR 30 for registering under the scheme and this amount is used to cover the administrative expenses incurred in implementing the scheme.

How does the Rashtriya Swasthya Bima Yojana scheme work?

The following is the step-by-step guide to how the Rashtriya Swasthya Bima Yojana scheme works –

• Firstly, the insurance companies who would provide health insurance coverage to beneficiaries are selected through a competitive public bidding. Both public sector and private sector companies can bid to provide coverage under the scheme. The company quoting the lowest annual premium per household becomes the appointed insurer per district.
• After the insurance companies are finalised, a list of eligible BPL families are prepared to identify the beneficiaries of the scheme. The State Governments prepare the BPL list and submit the list to the Central Government listing the eligible BPL families who are to be covered under the scheme.
• Once the eligible BPL families are identified, a schedule of enrolment is prepared by the insurance company. The schedule contains the time and date of enrolment and it is publicized at important places so that the families can enrol themselves. Thereafter, mobile enrolment stations are set up at local centres in every village.
• The beneficiaries can then enrol themselves by providing their biometric details and photographs. A smart card is issued to beneficiaries upon enrolment when the registration fee is paid. An information pamphlet which highlights the scheme and lists the eligible hospitals is also handed over to beneficiaries so that they can understand the scheme easily and know the hospitals where from they can avail cashless treatments.
• A Field Key Officer, who is a Government officer, and an insurance company or smart card company representative are present at the enrolment centres. The Field Key Officer is required to insert his/her own Government issued smart card which would verify and authenticate the beneficiary’s smart card.
• Once the beneficiaries are enrolled, the list of families who have been issued a smart card is sent to state nodal agencies for maintaining the records of beneficiaries.

Features of Rashtriya Swasthya Bima Yojana

The Rashtriya Swasthya Bima Yojana has various salient features which are as follows –

• The scheme provides cashless treatments to workers belonging to BPL families.
• A smart card is issued under the scheme which enables the beneficiary to avail cashless treatment at empanelled hospitals. The smart card is also portable in nature allowing beneficiaries to avail treatment across any hospital in India
• BPL families can choose public hospitals or private hospitals for availing medical treatments. The hospitals which are empanelled under the scheme would have to provide cashless treatments
• NGOs and MFIs have been involved in the Rashtriya Swasthya Bima Yojana to act as intermediaries. The involvement of these intermediaries would ensure better and wider coverage of the scheme
• The Government is paying only a minimal amount of INR 750 to provide the benefits of the scheme to BPL families. Thus, by paying this low amount the Government can implement welfare oriented policies for the poor.
• The smart cards are biometric enabled and are therefore safe and fraud proof
• A single smart card would be issued which would cover other Government sponsored schemes like the Aam Aadmi Bima Yojana and National Old Age Pension Scheme The scheme involves paperless transactions as online claims are submitted to the insurance company
• A Central Complaint and Grievance Redressal System (CGRS) has been implemented to handle complaints and grievances of beneficiaries and to provide them with quick solutions.
• From October 2014, enrolment in the Rashtriya Swasthya Bima Yojana has been linked to the individual opening a bank account and applying for an Aadhar card
• There is no limit on the maximum age of the beneficiary being enrolled in the scheme. Individuals of all ages can be covered under the Rashtriya Swasthya Bima Yojana if they belong to eligible BPL families.

Making a claim under the Rashtriya Swasthya Bima Yojana scheme

A claim under the Rashtriya Swasthya Bima Yojana happens when the beneficiary avails treatment at an empanelled hospital. To make a successful claim, the beneficiary should follow the following steps –

• He/she should approach the RSBY helpdesk at the empanelled hospital.
• The helpdesk would verify the identity of the beneficiary through the beneficiary’s photograph and fingerprints stored on his/her smart card.
• Once the identity of the beneficiary is verified, the individual can avail cashless treatment at the hospital
• In case of hospitalisation, the representative at the RSBY help desk would check the prescribed package rate of the ailment or injury for which hospitalisation has occurred. There is a pre-specified list containing various treatments and their package rate.
• If the reason for hospitalisation is due to an ailment or injury in the pre-specified list, the prescribed claim package is selected.
• If the treatment is not specified in the list, the representative would check with the insurance company regarding the applicable cost of treatment.
• The beneficiary can then avail cashless treatment at the hospital
• When the beneficiary is discharged, his/her smart card is swiped at the RSBY helpdesk to deduct the amount of the treatment from the coverage limit available on the smart card. The hospital also pays the beneficiary INR 100 towards transportation expenses. The beneficiary does not have to submit any proof to claim transportation expenses.
• After the treatment is done and the patient has been discharged, the hospital then sends an electronic report to the insurance company or its TPA stating the treatment done and the costs incurred.
• The insurance company or its TPA would verify the reports submitted and pays for the treatment costs directly to the hospital. This payment is done within a specified time period which is agreed upon between the hospital and the insurance company

Implementation and statistics of the Rashtriya Swasthya Bima Yojana scheme

The Rashtriya Swasthya Bima Yojana was launched in April 2008 and has been implemented in various phases so far. Here are the milestones in implementation of the scheme –

• The scheme was implemented in 25 states when it was launched on 1st April, 2008
• In the financial year 2012-13, INR 1096.7 crores was allocated to the Rashtriya Swasthya Bima Yojana in the Union Budget
• By February 2014, about 36 million families were covered under the scheme
• Starting from 1st April, 2015, the Rashtriya Swasthya Bima Yojana scheme would be implemented by the Ministry of Health and Family Welfare.
• The total number of hospitalisation claims made under the scheme till 31st March, 2016 stood at INR 11.8 million
• Currently, more than 3 crore workers and their family members are being covered under the scheme

The Central Complaint & Grievance Redressal System under the RSBY scheme

Grievances relating to the Rashtriya Swasthya Bima Yojana (RSBY) scheme can be longed online using Central Complaint and Grievance Redressal System (CGRS) portal. All the stake holders can file an online complaint about the RSBY Scheme. An Online facility to track the complaint real-time is also available.

The Road Ahead

The NDA Government has expressed its intention of increasing the coverage available under the scheme. The coverage might increase from the existing INR 30,000 per family to INR 1 lakh. Moreover, the Central Government also aims to make the scheme more widespread in India so that the maximum eligible population can be covered under the benefits provided by the Rashtriya Swasthya Bima Yojana.