Rashtriya Swasthya Bima Yojana was introduced in the year 2008 by the Ministry of Labor and Employment for unorganized workers in the country. The idea is to provide families below the line of poverty with the best healthcare services and social security.
The scheme is designed to help below poverty line families get access to the best medical facilities in town to rule of health hazards in regards to old age, maternity, disability and general ailments. The RSBY scheme was later expanded to make these benefits available to unorganized workers who are marginally above the poverty line.
Enrolment under the Rashtriya Swasthya Bima Yojana is possible only if the applicant meets each of the following criteria:
Listed below are some of the highlighting features of the Rashtriya Swasthya Bima Yojana:
Each family enrolled under this scheme receives health insurance coverage up to Rs. 30,000. The scheme covers up to 5 members below the poverty line households. Coverage for transportation charges i.e. Rs. 100 per visit to the hospital is also included in this scheme. The maximum coverage for transportation is Rs. 1,000.
The Rashtriya Swasthya Bima Yojana is applicable only for emergency situations. Cosmic surgeries and treatments are not covered. Certain medical conditions listed in the scheme are only covered when there is an actual medical emergency.
The treatment is cashless in nature. The insured can avail medical treatment at any hospital within the network providing the smart card issued by the Government. The authorities concerned shall verify the biometrics of the insured and initiate the treatment.
After the treatment, the claim of the insured is sent to the insurance service provider or Third Party Administrator electronically. After going through the electronic report the insured will initiate the payment within the prefixed time in the agreement.
The State Government is responsible to conduct a competitive public bidding procedure to select private or public insurance service provider(s). The insurance service provider is licensed by the IRDA to provide health insurance in India. The insurance service provider with the lowest bid is selected as the health insurance provider for RSBY.
The RSBY scheme is majorly financed by the Central Government (75%) and the rest is paid up by the governments in respective states. The only exceptions are the North-Eastern State and J&K where the Central Government pays for 90% of the cost and the State only has to fund the rest of the amount.
An electronic list of every family that belongs below the line of poverty registered in the district BPL list is sent to the insurance service provider. The insurance service provider prepares an enrolment list with specific dates for every village following which the list is posted at the enrolment station of every village.
The procedure for collection of biometrics and photographs of every member of the BPL family comes next. The beneficiary has to register for the scheme with Rs. 30. These beneficiaries will receive a smart card along with an information pamphlet that lists the names of the hospitals covered within the insurance network.
The legitimacy of the enrolment is authenticated by a Field Key Officer and a representative from the health insurance company. On authentication, a consolidated list is sent to the State Nodal Agency. The financial transfers from the Central to the State are based on the data on the list.
The Government at the State prepares and submits the BPL data in an electronic format to the Government of India. The details about the family members including the name, age, gender, name of the head of the household, and the member’s relationship with the head of the household are mentioned in the format. The scheme is implemented in the district based on the data provided by the State Government.
The empanelment of hospitals is done along with the selection of the health insurance service provider. The insurance service provider ensures that there are enough network hospitals in the district to make cashless treatment easily available to the insured. The hospitals within the network must have RSBY desks to attend to enquiries of the beneficiaries.
The procedure begins with the beneficiary visiting the network hospital. The insured has to go to the identity verification procedure at the RSBY desk. In the event of hospitalization of the insured, the concerned departments at the hospitals will verify the price and procedure for a specific package.
As the insured gets discharged from the hospital, he has to go through the verification of his biometrics and swipe his smart card to get the predetermined cost of the treatment deducted from the card. The insured is also eligible to get Rs. 100 for the transportation cost. However, he does not have to furnish any proof to get compensation for transportation.
The data collected in regards to the hospital transaction are sent to the district server via phone line. The data is arranged in pre-formatted tables for both the insurance company and the government. This makes it easy for the insurance service provider to keep a track of the claims & transfer money to the hospital.
RSBY is a unique cashless procedure to make medical treatment available to unorganized workers and their families living below the line of poverty. The coverage provided on a family floater basis can be utilized by the beneficiaries to tackle emergency medical situations. The RSBY scheme is secured with a robust evaluation procedure that allows the insurance service provider to track the claims as well as inspect dubious claim patterns to avoid potential discrepancies.
1. What is the policy start date and the terminal date for RSBY?
The policy start date for RSBY is 1st May and the terminal date for the plan is 30th April of the following year.
2. What are the documents the beneficiary must take to the hospital?
The beneficiary is only required to take the smart card to the hospital in the event of a medical emergency.
3. Is the cost of medicine and tests included in the coverage?
The cost of medicine and tests shall be covered only in the event of hospitalization of the insured. If there is no hospitalization, the insured must bear the charges for medicine and tests.
4. Is there a helpline number for the customers for coverage related queries?
Yes, the beneficiary will be provided with a helpline number along with the smart card on registration. The insured may use the number to enquire about the coverage, get information on claim status, or get general guidance on the service.
5. Can the members enrolled be changed?
In the event of the death of an existing member, another member whose name appears in the district BPL list can be enrolled in the deceased member’s place.
Written By : Naval Goel
Last Updated : May, 2020
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