Community health Nursing, Public health nursing, Nursing

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SMCH/HCDS/24: Health Insurance Scheme
Quadrant-I
Personal Details
Role Name Affiliation
Principal Investigator Prof. CP Mishra Department of Community Medicine,
Institute of Medical Sciences, Banaras Hindu
University, Varanasi
Paper Coordinator Prof. Najam Khalique Department of Community Medicine, J N
Medical College, AMU, Aligarh
Content Writer Dr. Tabassum Nawab
Assistant Professor
Department of Community Medicine, J N
Medical College, AMU, Aligarh
Content Reviewer Dr. Uzma Eram
Assistant Professor
Department of Community Medicine, J N
Medical College, AMU, Aligarh
Description of Module
Items Description of Module
Subject name Social Medicine & Community Health
Paper name Health Care Delivery System
Module name/Title Health Insurance Scheme
Module Id SMCH/HCDS/24
Pre-requisites Understanding of expenditure of health care.
Objectives To know about various health insurance schemes available in India.
Keywords
Central Government Health Scheme, Rashtriya swasthya Bima Yojna,
Universal Health Insurance scheme.

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Introduction:
Government supported insurance schemes are a form of social security in India. These schemes are
initiated by the Government to provide protection to certain sections of population against income
losses. In India, a number of Government supported insurance schemes have been initiated over the
last decade. A number of schemes that existed earlier have also been modified substantially. While
some of these changes have taken place at the State level, the most important changes, in particular
some of the largest insurance schemes in terms of implementation across the country have been
initiated by the Central government1.
Important health insurance schemes in India are:
 Rashtiya Swasthya Bima Yojana (RSBY)
 Employment State Insurance Scheme (ESIS)
 Central Government Health Scheme (CGHS)
 Aam Aadmi Bima Yojana (AABY)
 Janashree Bima Yojana (JBY)
 Universal Health Insurance Scheme (UHIS)
Learning objectives:
Upon completion this module, the reader should be able to enumerate.
 Describe objective, beneficiaries, benefits, services covered, financing and unique
features of Rashtiya Swasthya Bima Yojana (RSBY)
 Mention about coverage , administration , finance and benifits of Employment State
Insurance Scheme (ESIS)
 Describe components and benificiaries of Central Government Health Scheme (CGHS)
 Mention salient features of Aam Aadmi Bima Yojana (AABY)
 Mention salient features of Janashree Bima Yojana (JBY)
 State benifits provided under Universal Health Insurance Scheme (UHIS)
Main Text
1.Rashtiya Swasthya Bima Yojana (RSBY)
RSBY (Rashtriya Swasthya Bima Yojana) has been launched by Ministry of Labour and
Employment, Government of India on 1st April 2008 to provide health insurance coverage for Below
Poverty Line (BPL) families.
1.1.Objective :The objective of RSBY is to provide protection to BPL households from financial
liabilities arising out of health shocks that involve hospitalization.
1.2. Beneficiaries :
 The beneficiary is any Below Poverty Line (BPL) family, whose information is included in
the district BPL list prepared by the State government.
 Maximum of five members of a family-Husband, spouse and three dependents can be
enrolled.
 There is no age limit in RSBY.
 Beneficiaries need to pay Rs. 30 per family at the time of enrolment.

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1.3.Benefits :
 Rashtriya Swasthya Bima Yojana provides cover for hospitalization expenses upto Rs.
30,000/- for a family of five on a floater basis.
 Transportation charges are also covered upto a maximum of Rs. 1,000/- with Rs. 100/- per
visit.
1.4.Services covered :
[
A list of day care surgeries covered is provided below:
  Haemo-Dialysis
  Parenteral Chemotherapy
  Radiotherapy
  Eye Surgery
  Lithotripsy (kidney stone removal)
  Tonsillectomy
  D&C
  Dental surgery following an accident
  Surgery of Hydrocele
  Surgery of Prostrate
  Few Gastrointestinal Surgery
  Genital Surgery
  Surgery of Nose
  Surgery of Throat
  Surgery of Ear
  Surgery of Urinary System
  Treatment of fractures/dislocation (excluding hair line fracture), Contracture releases and
minor reconstructive procedures of limbs which otherwise require hospitalisation
  Laparoscopic therapeutic surgeries that can be done in day care
  Identified surgeries under General Anesthesia
  Any disease/procedure mutually agreed upon.
 Any disease that was present at any time in the past (including any disease, which the insured
person may not have been aware of) is treated as pre-existing. Pre-existing diseases are
covered under RSBY from day one itself.
 In case of smart cards issued from 1st April 2009, maternity benefits are covered.
 Both normal and caesarean deliveries are covered under RSBY. A hospital will be paid Rs.
2500 for normal and 4500 for caesarean delivery.A new-born is covered under RSBY since
birth automatically for the remaining period of the health insurance policy
 RSBY does not cover OPD expenses, or expenses in hospitals which do not lead to
hospitalisation.
 Food for the person who is hospitalized is covered in the package rate.
1.5.Finance :
Government pays the premium for RSBY. Central Government pays 75% of the total premium (90%
in case of Jammu & Kashmir and North east States) while State Government pays the remaining
premium.
1.6.Unique Features of RSBY

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The RSBY scheme is not the first attempt to provide health insurance to low income workers by the
Government in India. The RSBY scheme, however, differs from these schemes in several important
ways.
 Empowering the beneficiary– RSBY provides the participating BPL household with
freedom of choice between public and private hospitals and makes him a potential client
worth attracting on account of the significant revenues that hospitals stand to earn through the
scheme.
 Business Model for all Stakeholders– The scheme has been designed as a business model
for a social sector scheme with incentives built for each stakeholder. This business model
design is conducive both in terms of expansion of the scheme as well as for its long run
sustainability
 Insurers– The insurer is paid premium for each household enrolled for RSBY. Therefore,
the insurer has the motivation to enroll as many households as possible from the BPL list.
This will result in better coverage of targeted beneficiaries.
 Hospitals– A hospital has the incentive to provide treatment to large number of beneficiaries
as it is paid per beneficiary treated. Even public hospitals have the incentive to treat
beneficiaries under RSBY as the money from the insurer will flow directly to the concerned
public hospital which they can use for their own purposes. Insurers, in contrast, will monitor
participating hospitals in order to prevent unnecessary procedures or fraud resulting in
excessive claims.
 Intermediaries– The inclusion of intermediaries such as NGOs and MFIs which have a
greater stake in assisting BPL households. The intermediaries will be paid for the services
they render in reaching out to the beneficiaries.
 Government– By paying only a maximum sum up to Rs. 750/- per family per year, the
Government is able to provide access to quality health care to the below poverty line
population. It will also lead to a healthy competition between public and private providers
which in turn will improve the functioning of the public health care provider
 Information Technology (IT) Intensive – For the first time IT applications are being used
for social sector scheme on such a large scale. Every beneficiary family is issued a biometric
enabled smart card containing their fingerprints and photographs. All the hospitals
empanelled under RSBY are IT enabled and connected to the server at the district level. This
will ensure a smooth data flow regarding service utilization periodically.
 Safe and foolproof– The use of biometric enabled smart card and a key management system
makes this scheme safe and foolproof. The key management system of RSBY ensures that the
card reaches the correct beneficiary and there remains accountability in terms of issuance of
the smart card and its usage. The biometric enabled smart card ensures that only the real
beneficiary can use the smart card.
 Portability– The key feature of RSBY is that a beneficiary who has been enrolled in a
particular district will be able to use his/ her smart card in any RSBY empanelled hospital
across India. This makes the scheme truly unique and beneficial to the poor families that
migrate from one place to the other. Cards can also be split for migrant workers to carry a
share of the coverage with them separately.
 Cash less and Paperless transactions– A beneficiary of RSBY gets cashless benefit in any
of the empanelled hospitals. He/ she only needs to carry his/ her smart card and provide
verification through his/ her finger print. For participating providers it is a paperless scheme
as they do not need to send all the papers related to treatment to the insurer. They send online
claims to the insurer and get paid electronically.
2.Employment State Insurance Scheme (ESIS)
Employees’ State Insurance Scheme of India, is a multidimensional social security system tailored to
provide socio-economic protection to worker population and their dependants covered under the

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scheme. Besides full medical care for self and dependants, that is admissible from day one of
insurable employment, the insured persons are also entitled to a variety of cash benefits in times of
physical distress due to sickness, temporary or permanent disablement etc. resulting in loss of earning
capacity, the confinement in respect of insured women, dependants of insured persons who die in
industrial accidents or because of employment injury or occupational hazard are entitled to a monthly
pension called the dependants benefit.
2.1.CoverageApplicability
 The Act is applicable to non-seasonal factories employing 10 or more persons.
 The Scheme has been extended to shops, hotels, restaurants, cinemas including preview
theatres, road-motor transport undertakings and newspaper establishments employing 20* or
more persons.
 The Scheme has been extended to Private Medical and Educational institutions employing 20
or more persons in certain States/UTs.
*Note: 14 State Govts. / UTs have reduced the threshold limit for coverage of shops and ther
establishments from 20 to 10 or more persons. Remaining State Governments/UTs are in the process
of reducing the same. The existing wage limit for coverage under the Act is Rs. 15,000/- per month
( w.e.f. 01/05/2010)
Areas covered
The ESI Scheme is being implemented area-wise by stages. The Scheme has already been
implemented in different areas in the following States/Union Territories of Indian Union.
States :- All the States except Manipur, Sikkim, Arunachal Pradesh and Mizoram.
Union territories :- Delhi and Chandigarh
2.2.Administration :
The comprehensive and multi-pronged social security programme is administered by an apex
corporate body called the Employees' State Insurance Corporation. It comprises members
representing vital interest groups, including, employees, employers, the Central and State
Government, representatives of Parliament and medical profession. The Corporation is headed by the
Union Minister of Labour, as its Chairman, whereas the Director General, appointed by the Central
Government functions as its Chief Executive Officer. The broad based corporate body is, primarily,
responsible for coordinated policy planning and decision making for growth, development and
efficacy of the scheme. A Standing Committee, constituted from among the members of the
Corporation, acts as an Executive Body. The Medical Benefit Council, constituted by the Central
Government, is yet another Statutory Body that advises the Corporation on matters related to effective
delivery of medical services to the BeneficiaryPopulation.
The Corporation, with its Central Headquarters at New Delhi, operates through a network of 52
Regional, Sub- Regional and Divisional Offices located in various States. The administration of
Medical Benefit is taken care of by the respective State Government except in case of Delhi and
Noida/Greater Noida area in Uttar Pradesh where the Corporation administers medical facilities
directly. The Corporation has taken over the administration of 23 ESI Hospitals in various States for
developing them as ESIC Model Hospitals.

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2.3.Finance :
ESI Scheme, like most of the Social Security Schemes the world over, is a self financing health
insurance scheme. Contributions are raised from covered employees and their employers as a fixed
percentage of wages. As of now, covered employees contribute 1.75% of the wages, whereas, the
employers contribute 4.75% of the wages, payable to their employees. Employees earning upto
Rs.100/- a day are exempted from payment of their share of contribution. The State Governments, as
per provisions of the Act, contribute 1/8th of the expenditure of medical benefit within a per capita
ceiling of Rs. 1500/- per Insured Person per annum. Any additional expenditure incurred by the State
Governments, over and above the ceiling and not falling within the shareable pool, is borne by the
State Governments concerned
2.4.Benefits :
The section 46 of the Act envisages following six social security benefits :-
(a) Medical Benefit : Full medical care is provided to an Insured person and his family members
from the day he enters insurable employment. There is no ceiling on expenditure on the treatment of
an Insured Person or his family member. Medical care is also provided to retired and permanently
disabled insured persons and their spouses on payment of a token annual premium of Rs.120/- .
1. System of Treatment
2. Scale of Medical Benefit
3. Benefits to Retired IPs
4. Administration of Medical Benefit in a State
5. Domiciliary treatment
6. Specialist consultation
7. In-Patient treatment
8. Imaging Services
9. Artificial Limbs & Aids
10. Special Provisions
11. Reimbursement
(b) Sickness Benefit(SB) : Sickness Benefit in the form of cash compensation at the rate of 70 per
cent of wages is payable to insured workers during the periods of certified sickness for a maximum of
91 days in a year. In order to qualify for sickness benefit the insured worker is required to contribute
for 78 days in a contribution period of 6 months.
 Extended Sickness Benefit(ESB) : SB extendable upto two years in the case of 34 malignant and
long-term diseases at an enhanced rate of 80 per cent of wages.
 Enhanced Sickness Benefit : Enhanced Sickness Benefit equal to full wage is payable to insured
persons undergoing sterilization for 7 days/14 days for male and female workers respectively.
(c) Maternity Benefit (MB) : Maternity Benefit for confinement/pregnancy is payable for three
months, which is extendable by further one month on medical advice at the rate of full wage subject to
contribution for 70 days in the preceding year.
(d) Disablement Benefit
 Temporary disablement benefit (TDB) : From day one of entering insurable employment
& irrespective of having paid any contribution in case of employment injury. Temporary
Disablement Benefit at the rate of 90% of wage is payable so long as disability continues.
 Permanent disablement benefit (PDB) : The benefit is paid at the rate of 90% of wage in
the form of monthly payment depending upon the extent of loss of earning capacity as
certified by a Medical Board

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(e) Dependants' Benefit(DB) : DB paid at the rate of 90% of wage in the form of monthly payment
to the dependants of a deceased Insured person in cases where death occurs due to employment injury
or occupational hazards.
(f)Other Benefits:
Funeral Expenses : An amount of Rs.10,000/- is payable to the dependents or to the person who
performs last rites from day one of entering insurable employment.
Confinement Expenses : An Insured Women or an I.P.in respect of his wife in case confinement
occurs at a place where necessary medical facilities under ESI Scheme are not available.
In addition, the scheme also provides some other need based benefits to insured workers.
Vocational Rehabilitation :To permanently disabled Insured Person for undergoing VR Training at
VRS.
Physical Rehabilitation : In case of physical disablement due to employment injury.
Old Age Medical Care :For Insured Person retiring on attaining the age of superannuation or under
VRS/ERS and person having to leave service due to permanent disability insured person & spouse on
payment of Rs. 120/- per annum.
Rajiv Gandhi Shramik Kalyan Yojana : This scheme of Unemployment allowance was introduced
w.e.f. 01-04-2005. An Insured Person who become unemployed after being insured three or more
years, due to closure of factory/establishment, retrenchment or permanent invalidity are entitled to :-
 Unemployment Allowance equal to 50% of wage for a maximum period of upto one year.
 Medical care for self and family from ESI Hospitals/Dispensaries during the period IP
receives unemployment allowance.
 Vocational Training provided for upgrading skills - Expenditure on fee/travelling allowance
borne by ESIC.
Incentive to employers in the Private Sector for providing regular employment to the persons
with disability :
 Minimum wage limit for Physically Disabled Persons for availing ESIC Benefits is 25,000/-.
 Employerss' contribution is paid by the Central Government for 3 years.
Benefits & Contributory Conditions :
An interesting feature of the ESI Scheme is that the contributions are related to the paying capacity as
a fixed percentage of the workers wages, whereas, they are provided social security benefits according
to individual needs without distinction.
Cash Benefits are disbursed by the Corporation through its Branch Offices (BOs) / Pay Offices (POs),
subject to certain contributory conditions.
3.Central Government Health Scheme (CGHS)
The “Central Government Health Scheme” (CGHS) provides comprehensive health care facilities for
the Central Govt. employees and pensioners and their dependents residing in CGHS covered cities.
Started in New Delhi in 1954, Central Govt. Health Scheme is now in operation in Allahabad,
Ahemdabad, Bangalore,Bhubhaneshwar,Bhopal, Chandigarh, Chennai, Delhi, Dehradun, Guwahati ,
Hyderabad, Jaipur, Jabalpur, Kanpur, Kolkatta, Lucknow, Meerut , Mumbai ,Nagpur, Patna, Pune,
Ranchi, Shillong, Trivandrum and Jammu. The Central Govt. Health Scheme provides
comprehensive healthcare to the CGHS Beneficiaries in India. The medical facilities are provided
through Wellness Centres (previously referred to as CGHS Dispensaries) /polyclinics under
Allopathic, Ayurveda, Yoga, Unani, Sidha and Homeopathic systems of medicines.
The main components of the Scheme are:
 The dispensary services including domiciliary care
 F. W. & M.C.H. Services
 Specialists consultation facilities both at dispensary, polyclinic and hospital
level including X-Ray, ECG and Laboratory Examinations.
 Hospitalization

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 Organization for the purchase, storage, distribution and supply of medicines and other
requirements
 Health Education to beneficiaries
3.1.Beneficiaries :
 All Central Govt. employees and their dependant family membersresiding in CGHS
covered areas.
 Central Govt Pensioners and their eligible family membersgetting pension from Central
Civil Estimates
 Sitting and Ex-Members of Parliament
 Ex-Governors & Lt. Governors
 Freedom Fighters
 Ex-Vice Presidents
 Sitting and Ex-Judges of Supreme Court & High Courts
 Employees and pensioners of certain autonomous organizationsin Delhi
 Journalists (in Delhi )Accredited with PIB( for OPD & at RML Hospital)
 Delhi Police Personnel posted in Delhi
 Railway Board employees
4.Aam Aadmi Bima Yojana(AABY)
Aam admi bima yojana, a Social Security Scheme for rural landless household was launched on 2nd
October, 2007. The head of the family or one earning member in the family of such a household is
covered under the scheme. The premium of Rs.200/- per person per annum is shared equally by the
Central Government and the State Government. The member to be covered should be aged between
18 and 59 years.
4.1.Benefits :
On natural death Rs 30000
On death due to accident / on permanent disability due to accident ( loss of 2 eyes
or 2 limbs )
Rs 75000
On partial permanent disability due to accident( loss of one eye or one limb Rs 37,500
A separate fund called "Aam Admi Bima Yojana Premium Fund" has been set up by Central Govt. to
pay the Govt. contribution. Fund is maintained by LIC. A free add-on benefit in the form of
scholarship to children is also available under the Scheme.
5. Janashree Bima Yojana:
Janashree Bima Yojana (JBY) was launched on 10th August 2000. The Scheme replaced Social
Security Group Insurance Scheme (SSGIS) and Rural Group Life Insurance Scheme (RGLIS). 45
occupational groups have been covered under this scheme
No Occupation No Occupation
1 Beedi workers 23 Power loom workers
2 Brick kiln workers 24 Hilly area woman
3 Carpenters 25 Food stuffs like khandsari/Sugar
4 Cobblers 26 Textile

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5 Fisherman 27 Manufacture of food products
6 Hamals 28 Manufacture of paper products
7 Handicraft Artisans 29 Manufacture of leather products
8 Handloom Weavers 30 Printing
9 Handloom & Khadi weavers 31 Rubber and coal products
10 Lady Tailors 32 Chemical products like candle
manufacture
11 Leather Tannery workers 33 Mineral products like earthern toys
manufacture
12 Papad workers attached to SEWA 34 Agriculturists
13 Physically handicapped self employed
persons
35 Transport drivers association
14 Primary milk producers 36 Transport karmacharis
15 Rickshaw pullers/Auto Drivers 37 Rural poor
16 Safai karmacharis 38 Construction workers
17 Salt growers 39 Fire crackers workers
18 Tenduleaf collectors 40 Coconut processors
19 Scheme for urban poor 41 Aanganwadi Workers/Helpers
20 Forest workers 42 Kotwal
21 Sericulture 43 Plantation workers
22 Toddy tappers 44 Woman associated with SHG
45 Sheep breeders
It provides life insurance protection to people who are below poverty line or marginally above poverty
line. Persons between aged 18 years and 59 years and who are the members of the identified 45
occupational groups are eligible to be covered under the Scheme
6.Universal Health Insurance Scheme (UHIS)
The four public sector general insurance companies have been implementing Universal Health
Insurance Scheme for improving the access of health care to poor families.
6.1.Benefits :

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 The scheme provides for reimbursement of medical expenses upto Rs.30,000/- towards
hospitalization floated amongst the entire family.
 Death cover due to an accident @ Rs.25,000/- to the earning head of the family.
 Compensation due to loss of earning of the earning member @ Rs.50/- per day upto
maximum of 15 days.
 The Universal Health Insurance Scheme (UHIS) has been redesigned targeting only the
BPL families. The premium subsidy has been enhanced from Rs.100 to Rs.200 for an
individual, Rs.300 for a family of five and Rs.400 for a family of seven, without any
reduction in benefits.
Summary
The various health insurance schemes run by Govt. of India at centre and state level aims to reduce
the burden of expenditure/ income loss on treatment by the citizens especially focussing on the
underprivilged sections of the society. However, due to lack of awareness, poor political commitment,
corruption, poor quality services etc, the utilization rates are poor that needs to be taken care of to
reduce the burden & improve the quality of the citizens.
References:
1. Mita Choudhury and Srinivasan.A Study on Insurance Schemes of Government of India, final
report 2011.
2. http://www.rsby.gov.in/.
3. http://www.esic.nic.in/index.php.
4. http://msotransparent.nic.in/cghsnew/index.asp.
5. http://financialservices.gov.in/insurance/gssois/aaby.asp.
6. https://www.licindia.in/aam_admi_features.htm.
7. http://financialservices.gov.in/insurance/gssois/uhis.asp.