HEALTH SCHEMES AND INSURANCE

Health insurance programme, people who have the risk of a certain event contribute a small
amount (premium) towards a health insurance fund. This fund is then used to treat patients
who experience that particular event (e.g. hospitalization).
Definition “Health insurance, like other forms of insurance, is a form of collectivism by
means of which people collectively pool their risk, in this case the risk of incurring medical
expenses.”
OBJECTIVES
Health insurance programme have two main objectives:
• To increase the access to health care
• To protect the employees from high medical expenses at the time of illness.

HISTORY OF HI IN INDIA
• 1923: Workman’s compensation Act.
• 1948: ESI Act passed.
• 1952: First ESI hospital established.
• Mudaliar Committee(1959-1961) recommendations: – Long range health insurance policy
for all. – Small fee for availing health services.
• 1999: IRDA act passed.
• 2001: Insurance amendment Act

PRINCIPLES OF INSURANCE
Utmost good faith
– Insurer and the insured should have good faith to each other
– Insurer must provide complete & accurate information
– the insurance contract must be signed by both parties (i.e insurer and insured) in
an absolute good faith or belief or trust.

Insurable interest
– Insured must have insurable interest in the subject matter of the insurance
– For example :- The owner of a taxicab has insurable interest in the taxicab because
he is getting income from it. But, if he sells it, he will not have an insurable
interest left in that taxicab.
–
Principles of indemnity
– Indemnity means security, protection and compensation given against damage,
loss or injury.
– According to the principle of indemnity, an insurance contract is signed only for
getting protection against unpredicted financial losses arising due to future
uncertainties.

Principle of Subrogation
– Subrogation means substituting one creditor for another.

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Principle of loss minimization
– It is the duty of the insured to take all possible step to minimize the loss to the
insured items on the happening of the uncertain event.

CHARACTERISTICS OF HI
• It is contract between an insurance company and an individual or his sponsor (e.g. an
employer).
• The contract can be renewable annually or monthly.
• The type and amount of health care costs that will be covered by the health insurance
company are specified in advance, in the member contract or "Evidence of Coverage"
booklet.

HEALTH SCHEME IN INDIA

IT IS MAINLY CLASSIED INTO FOUR
-Mandatory Health Insurance schemes -The two mandatory government run schemes
includes:
 [Link] Government Health Schemes (CGHS)
 2. Employee’s state insurance scheme (ESIS
-Employer based scheme -The railways, defense and security forces provides medical
benefits to the employees
-Voluntary Health Insurance Schemes Or Private For Profit Scheme

-The Government of India has brought out several Health schemes that are run for the health
benefits of the common man. A few notable ones among them are:

1. Rashtriya Swasthiya Bima Yojana (RSBY)

2. Aam Aadmi Bima Yojana (AABY) and Janashree Bima Yojana (JBY) 
3. PMJAY- Ayushman Bharat

1. Central Government Health Scheme (CGHS): 

The CGHS Scheme is devised for the employees under Central Government services. It has a
wide range of benefits for the employees. The benefits can be enjoyed by the current working
people and also the ones who have retired from the Central Government Services.  Their
dependents are also eligible to enjoy the similar benefits.  The facilities that are available
under this scheme are available in all the state capitals along with the major cities and towns
of India. Full-fledged health services are admissible under this Health Scheme.

INTRODUCTION
 Started under the Indian ministry of health and family welfare in 1954.
 The scheme was started in Delhi in 1954.

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  The scheme was extended to the17 cities all over the India (allahabad,ahmedabad,
bangalore,mumbai,kolkata,hyderbad,jaipur ,jabalpur, lucknow ,Chennai ,westbengal ,
nagpur, patna , pune ,kanpur,guwahati, thiruvananthapuram.

Documents Required :
The patient must have the authentic document to prove that he is a Central Government
employee (working or retired).

WHY/ OBJECTIVES

PRICE

AWARENESS – by creating awareness and by keeping same price. Started from Delhi they
extended their scheme to 17 different cities .
PROMOTE- government promoted their scheme in urban hospital and health centre. Health
service and health insurances war provided by the government. So that demand is generated
forward health
PREVENT – to prevent and control locally endemic diseases E.q fever , dengue
 To provide immunization service
 Manage common diseases and injuries.

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Components of the Central Government Health Scheme (CGHS)

 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.
 Organization for the purchase, storage, distribution and supply of medicines and other
requirements.
 Health Education to beneficiaries.

Beneficiaries of the Central Government Health Scheme (CGHS)

 The current working employees of Central Government and their dependent family
members living in CGHS covered areas.
 Existing and Former members of the Indian Parliament.
 Former governors & Lieutenant governors of India.
 Freedom Fighters of India.
 Former Vice Presidents of India.
 Existing and Former Judges of Supreme Court & High Courts of India.
 Workers and Pensioners of selected autonomous organizations in the Delhi state.
 Journalists qualified with PIB (In Delhi Only).
 Police Personnel (In Delhi Only).
 Workers of Railway Board.

Eligibility for Central Government Health Scheme

 All employees of the central government who receive wages from the Central Civil
Estimates.
 All dependent family members of Central Government employees who receive wages
from Central Civil Estimates and are residents of areas covered under CGHS.
 Pensioners and family pensioners of the Central Government.
 Eligible dependent family members of pensioners and family pensioners of the
Central Government.
 Members of parliament
 Ex-vice presidents
 Ex-Governors & Lt. Governors
 Retired/sitting judges of high courts and Supreme Court.
 Freedom fighters
 Journalists accredited with Press Information Bureau
 Employees of the Railway Board
 Delhi Police Personnel in Delhi only
 Pensioners and employees of certain statutory/autonomous bodies that have been
extended CGHS facilities in Delhi.
 Post and Telegraph Department Employees.

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Types of Medical Systems Covered Under CGHS

CGHS provides health care through following systems of Medicine:

 Allopathic
 Homoeopathic
 Indian system of medicine
o Ayurveda
o Unani
o Siddha and
o Yoga

Facilities Offered Under Central Government Health Scheme (CGHS)

 OPD Treatment including issue of medicines.

 Specialist Consultation at Polyclinic/Govt. Hospitals.
 Indoor Treatment at Government and Empanelled Hospitals.
 Investigations at Government and Empanelled Diagnostic centers.
 Cashless facility available for treatment in empanelled hospitals and diagnostic
centers for Pensioners and other identified beneficiaries.
 Reimbursement of expenses for treatment availed in Govt. /Private Hospitals under
emergency.
 Reimbursement of expenses incurred for purchase of hearing aids, artificial limbs,
appliances etc. as specified.
 Family Welfare, Maternity and Child Health Services.
 Medical consultation and dispensing of medicines in Ayurveda, Homeopathy, Unani
and Siddha system of medicines (AYUSH).

Cost of Central Government Health Scheme (CGHS) Facilities

The cost of CGHS facilities differs for the serving employees and the pensioners of the
central government of India.

For Pensioners
In case a pensioner wants to avail the facilities of CGHS they will also have to make a
contribution according to the grade pay they were entitled at the time of their service. The
contribution can be done as yearly contribution and one time contribution:

 Yearly Contribution: Every year a certain amount of money (as per grade pay) is to be
contributed towards CGHS.
 One Time Contribution: A pensioner pays onetime contribution amount towards
CGHS for 10 years. It will be considered as a life time contribution.

For Serving Government Employees

A central government employee, who is currently serving in CGHS covered area, is bound to
take the CGHS card. A deduction is made from the salary by their department every month,
which depends upon the grade pay of the serving employee.

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Required time to get CGHS Card
A printed index card of CGHS is issued on the day of application for CGHS. Later, the
plastic cards are issued and sent to the concerned card holders within 3 weeks. The cards are
sent to the residence of the government employees.

Treatments Not Covered Under Central Government Health Scheme (CGHS)

Follow-up and In-patient Treatments are not addressed in case of the following:

 In case of a declared emergency, the treatment can be done at any hospital, but the
reimbursement claim can only be submitted to the Additional General where the
CGHS card is registered.
 In case of reimbursement of medical bills, the beneficiary can be treated at any
hospital and the claim amount will be limited to the rates as per mentioned under
CGHS. The reimbursement claim can only be submitted to the Additional General
where the CGHS card is registered.

Central Government Health Scheme (CGHS) & Mediclaim Policy

An individual may have a Mediclaim insurance policy also along with the CGHS. If due to
the medical emergencies, the individual is treated in a private hospital, and some of the bills
are paid by the insurance company, the individual will still be able to get the rest of the cover
from CGHS.
All the medical bills submitted to the insurance company and the duplicate bills with
certificate from Insurance Company will be claimed from CGHS by the pensioner. The
serving employees will have to contact their concerned departments for getting the balance
from CGHS.

CGHS in Private Hospitals-

CGHS is only provided in the Government hospitals and the empaneled private hospitals
under CGHS. But if an individual faces an emergency and is treated from a non-empaneled
private hospital, the expenses are reimbursed as per normal CGHS rates.

Surgeries at Private Empaneled Hospitals under CGHS-

• Before proceeding for doing a surgery, an individual will have to obtain advice from a
government specialist/ CMO i/c of Wellness Center.
• However, to obtain advice, pensioners will have to apply to CMO i/c of Wellness
Center for getting the permission before doing the surgery. However, CGHS will
provide reimbursement at CGHS rates to contact their respective department/office.
• Central Government Health Scheme is an important and unique scheme that is
introduced in India to help the Government employees in providing medical care.

How it is useful for people

• Over 15 lakh people have been benefited from health scheme.
• The people of the country are one of its most valuable resources.

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 • These programs are aimed at increasing the standard of health of the people and
decreasing the incidence of disease and death due to illness.

2. EMPLOYMENT STATE INSURANCE SCHEME (ESIS)

It is a social security scheme that takes care of the worker class.  There is a huge worker
category of persons who are engaged in different establishments such as factories etc. who
are always under the threat of health hazards and injury. These people get their coverage
benefit along with that of their dependents. If the workers in a factory are more than 9, ESI
becomes applicable for the workers. Apart from the factories, the workers in other
establishments such as shops, hotels, cinema halls, transport sector employees are all covered
under ESI. The workers in these establishments have to be 20 persons minimum for the
coverage to be binding. Staffs working in the educational institutes are also covered by ESI.
All areas in the country are not yet covered by ESI. Gradually, the areas are being increased. 

Documents Required :
The person should possess the ESI card to avail the facility.

Benefits :
If a person becomes sick, they are eligible to get cash benefits by availing the treatment at the
notified ESI hospitals. If a person undergoes temporary or permanent disability, he will get
the benefit from it. If a person becomes incapacitated, he will get a pension monthly to run
his household expenses. The same will be given to the family members, if the person dies due
to any kind of injury during the course of employment. 

APPLICABILITY Act applies to factories using power not using AND Employing 20 or
more persons. Gradually extended to the following:
 Smaller power-using factories with 10-19 persons
 Non-power factories with 20 or more persons
 Shops
 Hotels and restaurants
 Cinemas including preview theaters
 Newspaper establishments
 Road motor transport undertakings employing 20 or more persons
 State govt may cover other establishments in consultation with the ESI corporation
and with approval of the central govt.

DEFINATION
Employee- Employee refers to any person employed on wages in connection with the work of
a factory or establishment to which this act applies.
 Includes technical, manual, clerical and supervisory functions
 Persons with remuneration upto Rs.6500 are covered under the act.
 No distinction between casual and temporary employees or technical and non-
technical, or timerate or piece-rate
 Covers admin staff and those in purchase
 Does not include naval, military or air force personnel.

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Wages: means all remuneration paid in cash, including payment in period of leave, lockout or
strike which is not illegal. Does not include:
 Contribution paid to the provident fund or pension fund
 Travelling allowance
 Sum paid to defray special expenses
 Gratuity payable on discharge
Contributions
Main sources of finance are contributions from employers and employees, and 1/8th share of
expenses by state governments.
 Employee’s contribution 1.75% of wages
 Employer’s contribution 4.75% of total wages
 Total amount to be deposited in the state bank of India or other authorised bank by
21st of the month following the month when the wages became due.
An employer who fails to pay within the specified period is liable for fines and damages for
late payment
Employees with daily wages below Rs 40 are exempt; however employer’s contribution
applicable.

Registration
 Registration of a factory/establishment with the employees state insurance corporation
(ESIC) is a statutory responsibility of the employer under section 2-A and 10-B.
 Declaration of registration in form to be furnished to the appropriate regional office
within 15 days of the act becoming applicable.
 Employer should get the declaration form filled in by every employee covered under
the scheme.

MAINTENANCE OF REGISTERS
The statutory registers to be maintained up to date are:
A) Register of employees
B) Accident book in which every accident to employees during the course of employment is
recorded
C) Inspection book (to be produced before an inspector or authorised officer.)

ADMINISTRATION

 The scheme is administered by the esic (employee’s state insurance corporation)

Chairman: Union minister for labour
 Comprises groups like employers, employees, parliament, state and central govt. And
the medical profession.
 A standing committee drawn from this broad based body is responsible for policy,
planning and decision making.
 The chief executive officer of the corporation is Director general of esic
 Ex officio member of the corporation
 Member of the standing committee Responsible for Formulation of policy ,Overall
supervision ,Co-ordination and liaison with central and state governments.
 Esic has set up regional offices all over India. Each office is under the charge of the
regional director who maintains records and administers local offices.

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 BENEFITS

 Sickness and extended sickness benefit

 Maternity benefit
 Disablement benefit
 Dependants’ benefit
 Medical benefit
 Funeral benefit
 Rehabilitation benefit

SICKNESS AND EXTENDED SICKNESS BENEFIT

 Represents periodical payments made to an insured person for the period of certified
sickness after completing 9 months in insurable employment.
 To qualify, contributions should be for minimum 78 days in the relevant period.
 Maximum duration for benefit is 91 days
 Rates of payment vary from Rs.14-125 per day, i.e. Average of 50% of daily wages.
 Insured persons suffering from TB, leprosy, mental and malignant diseases or other
specified long term diseases are entitled to extended benefits at higher rates, provided
he has been continually employed for at least two years.

MATERNITY BENEFIT
 Implies cash payment to an insured woman in case of confinement or miscarriage or
sickness arising out of pregnancy or premature birth.
 Woman should have contributed for minimum 70 days in the preceding two
consecutive contribution periods.
 Daily rate of benefits double the standard sickness benefit rate, i.e. Full wages.
 Normally payable for max 12 weeks for confinement and 6 weeks for miscarriage or
medical termination of pregnancy.
 Payable even in the event of the death of the woman.

DISABLEMENT BENEFIT
 In case of temporary disability arising out of employment injury, this benefit is
admissable for the entire period certified by an insurance medical officer/practitioner
for which the insured person does not work for wages.
 Rate payable not less than 70% of daily wages; minimum 3 days of incapacity
required.
 In case injury results in permanent, partial or total loss of earning capacity, periodical
payments to be made for life. One-time lumpsum is permissible in certain cases.

DEPENDANT’S BENEFIT
 Periodical pension paid to dependants of deceased where death occurs out of
employment injury or disease.
 Widows: 3/5th of benefit rate for life or until remarriage
 Children: 2/5th of benefit rate until 18
 Total amount distributed not to exceed ceiling of disablement benefit.
 Benefit not paid to married daughters.
 In case there is no widow or child, benefit can be paid to other dependants including
parents.

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  Amount paid is reviewed and increases granted from time to time to compensate for
erosion in real value and cost of living.

MEDICAL BENEFIT
 Insured persons and their families entitled to free, full and comprehensive medical
care.
 Extended upto two years for chronic and long-term diseases.
 Treatment continues even if person goes out of coverage, till sickness ends.
 Package covers all aspects of health care from primary to super-specialist facilities,
such as: 1. Out-patient treatment 2. Domiciliary treatment 3. Specialist consultation
and diagnostic facilities
 In-patient treatment , Free supply of drugs and dressing
 .X-ray and laboratory investigations
 Vaccination and preventive innoculations
 Ante-natal, confinement, post-natal care
 Ambulance service or conveyance charges
 Free diet during admission in hospitals
 Free supply of artificial limbs, aids and appliances for physical rehabilitation
 Family welfare services and other national health programme services
 Medical certification
 Special provisions including super-speciality treatment

FUNERAL BENEFIT
 Funeral expenses are in the nature of a lump sum payment upto a maximum of
rs.2500 made to defray the expenditure of the funeral of deceased insured person.
 The amount is paid either to the eldest surviving member of the family or, in his
absence, to the person who actually incurs the expenditure on the funeral.

REHABILITATION BENEFIT
 The corporation grants rehabilitation allowance to the insured persons for each day on
which they remain admitted in an artificial limb centre, on the rates, which generally
conform to double the standard sickness benefit rate.
 All benefits under the esi scheme are paid in cash except medical benefit, which is
given in kind.

RESTRICTIONS
A person entitled to ESI benefits shall not be entitled to any other benefit. Further an insured
person will not be entitled to receive for the same period:
 Both sickness and maternity benefit, or
 Both sickness and maternity benefit for temporary disablement, or
 Both maternity and disablement benefit for temporary disablement.
Where a person is entitled to more than one of the benefits, he has an option to select any one
of them.

PENALTIES AND DAMAGES

 If a person commits an offence after being convicted by a court, every subsequent
offence attracts imprisonment upto 1 year or fine upto rs.2000 or both.

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  If the subsequent offence is for failure to pay contribution, punishment will be upto 1
year and not less than 3 months, and fine upto rs.4000.
 Contribution can be recovered through the district collector as arrears of land revenue.
 Employer is liable for 6% interest p.A. For each day of default or delay in payment of
contribution.
 Power to levy damages is discretionary and in the nature of a quasi-legal provision.
Reasonable opportunity to the employer to be given before levying damages.

MISCELLANEOUS
 Cash benefits payable under the esi act are not liable to attachment or sale in
execution of any court decree or order.
 Right to receive benefit is not transferable.
 Disputes under the provisions of the act to be decided by the employees’ insurance
court (eic) and not by a civil court. Appeals to the high court only by an order of the
eic on a question of law.
 Period of limitation for appeal is 60 days.

OBLIGATIONS OF EMPLOYERS
 Get his factory registered within 15 days of the act becoming applicable, by supplying
information in prescribed form. Obtain code number.
 Arrange allotment of insurance number to all employees covered by the act by
completing their declaration forms and submitting them to the regional office.
 Assist employees in obtaining their identity certificates, and pending this issue
certificates of employment to enable employees to avail of cash and medical benefits
meanwhile.
 .He should not dismiss or punish any employee during period of medical treatment or
if absent from work as a result of illness.
 Maintain up to date registers and records of the establishment and afford facilities for
easy inspection.
 Reimbursement to the corporation excess expenditure incurred due to insanitary
working and living conditions in the establishment or housing colony of its employees

OBLIGATIONS OF EMPLOYEES
 Assist employer in obtaining registration, insurance number and id cards from the esi
authorities.
 Obtain necessary sickness/other certificates from the medical authorities for claiming
cash benefits.
 Give proper notice to employer of accident causing employment injury and submit for
medical examination as an when necessary to claim benefits.
 Repay to the esic any benefit to which he was not entitled.
 Submit claims within prescribed time along with prescribed documents.

3. RASHTIYA SWASTHIYA BIMA YOJANA (RSBY)

The Indian Government is committed to providing the health insurance facilities for all its

citizens. It is seen that the unorganized sector is the group which is the most deprived and
does not have much social security benefits. An Act was made in 2008 for ensuring the
Social security of this unorganized category in India. This scheme was launched in 2008. In

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the beginning, this scheme was made mainly for the people under the BPL category. Now it
has not been kept restricted to the under BPL category. Many other workers in the
unorganized sector have been brought under this scheme.

Details of the RSBY

According to the RSBY as launched in 2008 –
 Every BPL family holding a valid ration card may enrol to avail the insurance benefits
as extended by the scheme;
 INR 30 will be charged as a one time registration fee;
 Upto 5 members of the family including one head of household, spouse and three
dependent persons (children or parents) may be covered under the insurance scheme;
 Each family is entitled to claim (cashless) inpatient medical care up to INR 30,000 per
annum;
 The hospitalization may be done in any of the empanelled hospitals;
 Pre existing ailments will be covered from Day 1 of the enrolment;
 Each family may also claim transport expenses of INR 100 per hospitalisation subject
to a maximum of INR 1000 per family per annum.
Aim
The premium that has to be paid for this health scheme is jointly borne by the Union and the
State Governments. It is envisioned as a very strong health scheme that will cover the
majority of the unorganized sector in India. This Scheme is under the overall control of
the Ministry of Health & Family Welfare. The major 2 objectives of this scheme is to provide
financial assistance to high costs in health protection and enhance the accessibility of
standard health care features for the members of the BPL category of people. The
beneficiaries are the people who are under the BPL category.

Features :
 The following are the salient features of the RSBY Health Scheme :

 Independence of the beneficiary: The beneficiary is free to choose among

the government and the private hospitals for availing the treatment. The hospitals can
also be gainers by treating these patients. There are good amounts of earning that
these people can fetch the hospitals.
 Win-win situation for all the stakeholders: This scheme is been framed in such a
manner that it is beneficial to all the stakeholders who are involved with this scheme.
It is a well-devise scheme that can be run for a long time as all the parties concerned
can benefit from it.
 Insurance Company: The Company gets its income from the premium of the
insured. The more number people covered will ensure a larger income for the
company. It is also in turn a benefit to the insured as their risks are getting covered.
 Hospitals/Medical Centers: With the greater number of patients being treated at their
premises, the revenue of the hospitals is also found to rise. The hospital is always
inclined to attract the most number of patients.
 Intermediary organizations: The organizations which have an intermediary role
such as the NGOs are responsible for enrolling the BPLs and extending the scheme
related services to them. The more they can do, the greater are their income
generations.

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  Government: The Government is responsible for meeting the needs of the country’s
citizens. It becomes a big challenge for meeting this need to such a huge population
spread over so big a land. The Government pays the premium for the people under the
BPL category and is able to render the required medical services.
 Digitally enabled: This scheme is enabled digitally. All the member families are
handed over a card that is digitally enabled. It contains all the relevant data of the
family members including the photos and the fingerprints. It enables a smooth process
of operation. The digital method makes the system entirely safe. No one is able to
tamper with the card. No middleman can take any benefit in between. The entire
process remains clear and transparent. The duplication of the card is not possible. The
storage of the patient data becomes authentic and foolproof.
 Can be availed anywhere in India: The RSBY scheme is not restricted only to the
region of the beneficiary’s residence. A person can just present his card to a listed
hospital throughout India to avail the desired services. It is useful to the workers if
they have to shift to a new place of work.
 No monetary transactions required: If the cards are used at an empanelled
hospitals, the beneficiary can avail the cashless services. It is easier for the patients to
avail the services.
 Error-free tracking: The reports regarding the availing of the scheme can be fetched
at any moment easily. The entire data is stored on the server and a real-time data can
be retrieved. 

Documents Required:
The person should be a holder of the BPL card to avail this scheme. Workers in the
unorganized sector also can avail the scheme. A Government specified list of 11 categories of
unorganized sector is defined. These people have to show the proof of their occupation. 

Benefits
The beneficiary shall be eligible for such in - patient health care insurance benefits as would
be designed by the respective State Governments based on the requirement of the people/
geographical area. However, the State Governments are advised to incorporate at least the
following minimum benefits in the package / scheme:
 The unroganised sector worker and his family (unit of five) will be covered.
 Total sum insured would be Rs. 30,000/- per family per annum on a family floater
basis.
 Cashless attendance to all covered ailments
 Hospitalization expenses, taking care of most common illnesses with as few
exclusions as possible
 All pre-existing diseases to be covered
 Transportation costs (actual with maximum limit of Rs. 100 per visit) within an
overall limit of Rs. 1000.

Scheme Rollout And Target Beneficiaries

The Rashtriya Swasthya Bima Yojana (RSBY) is a health insurance scheme that aims at
providing health insurance coverage to the poor families of India. It provides cashless
insurance coverage for hospitalization in both private and public hospitals. The cost of the
insurance premium is borne by both the central (75 percent) and state (25 percent)

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 governments. Initially, the scheme was launched by the Ministry of Labour and Employment,
but was transferred to the Ministry of Health and Family Welfare on 1 April, 2015.
The RSBY was rolled out in 25 states of the country on 1 April, 2008. By February 2014, a
total of 36 million families have been covered under the scheme.

The initial intention of the Rashtriya Swasthya Bima Yojna (RSBY) was to provide
healthcare and financial relief only for those the Below Poverty Line (BPL). It later evolved,
however, to cover other workers and their families not initially envisaged within the purview
of the scheme –
These include –

 MNREGA workers who have been employed for over 15 days in the previous
financial year
 Domestic helpers and workers
 Sanitation workers
 Miners and mine workers
 Rickshaw pullers and auto and taxi drivers
 Street vendors and railway porters
4. AAM AADMI BIMA YOJANA (AABY) AND JANASHREE BIMA YOJANA (JBY)
 The beneficiary of the AABY scheme has to belong to landless persons in the rural areas. A
single member of the family gets the benefit of this health scheme. The wage earner of the
family is the person who gets the benefit of this scheme. The person has to be with the age of
18 to 59 to qualify. The premium is paid by the Centre and the State equally. The coverage is
for people under the BPL category or slightly above the limits for the JBY Scheme. Both
these schemes have now been combined.
– Why was Aam Aadmi Bima Yojana Launched?
This particular scheme was launched as late as October, 2007. This means that the
requirement for such a scheme existed in the late 2000s. It is essential to understand what the
basic requirement of this is in the Indian economy. Aam Aadmi Bima Yojana is intended for
social security and financial aid to the people of rural India. This not only includes people
below the poverty line but also people living in areas which do not have access to urban
facilities such as big hospitals, or even a pharmacy for that matter. With changing topography
of the Indian economy and the middle class and above being able to pull themselves along
with changing times, people of rural India, who form the majority are falling back due to the
lack of aid. This particular scheme intends to aid people at such a time.

BENEFITS OF AAM AADMI BIMA YOJANA:

The benefits under Aam Aadmi Bima Yojana scheme are as follows:
1. The Death Benefit Of this scheme is given to the surviving nominees or family of the
policyholder on the event of a natural death is Rs. 30,000/-.
2. In case the death has occurred due to accident/on permanent total disability due to
accident (loss of 2 eyes or 2 limbs) the amount given to the nominees or family members
of the owner of the policy is Rs. 75,000.
3. In the case of partial permanent disability due to accident (loss of one eye or one
limb) the amount given to the nominees or family members of the owner of the policy is
Rs. 37500/-

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4. Scholarship benefits: Scholarship is a Free Add-on benefit provided to a maximum of
two children of the beneficiary who are studying between 9th to 12th Standard @ Rs.100/=
per month for each child, which is payable at a half yearly basis – July 1 and on January 1,
every year.
ELIGIBILITY CRITERIA FOR AAM AADMI BIMA YOJANA:
The following are the basic requirements for applying for the Aam Aadmi Bima Yojana:
 The applicants should be aged between 18 and 59.
 The applicant ideally should be the head of the family or one of the earning members
of a below poverty line family (BPL) or marginally above the poverty line under identified
vocational group/rural landless household.
 Some documentation is also required.
DOCUMENTATION REQUIRED FOR AAM AADMI BIMA YOJANA APPLICATION:
The following are the documentation requirements to apply for this scheme:
 Ration Card
 Extract from Birth Register
 Extract from School Certificate
 Voter’s List
 Identity card issued by reputed employer/Government Department.
 Unique Identification Card (Aadhar Card)
PROCEDURE TO CLAIM AAM AADMI BIMA YOJANA:
The death or disability claims which are under this scheme are supposed to be settled by the
P&GS Unit of LIC. They make a direct payment to the beneficiaries through NEFT. In the
case that there isn't a NEFT facility available, the money for the claim is directly transferred
to the bank account of beneficiaries. This would also require prior approval from competent
authority, the A/C payee cheque or claim can be paid by any other mode as decided by LIC.
Death Claim Procedure:
1. In the event of death of the member during the period of coverage and while the
policy is in force, an application has to be made by his/her nominee.
2. This application should be made along with a Death Certificate for payment of claim
amount to the designated official of the Nodal Agency.
3. The designated official of the particular Nodal Agency has to then verify the claim
papers.
4. The officer will then submit the documentation and application along with the death
certificate and a certificate that the deceased member was head /earning member of the
family belonging to the BPL/Marginally above BPL family under the eligible occupations
under the scheme.
5. Nodal Agency has to submit the following with the application:
1. Claim Form duly completed in all respects
2. Original death certificate along with a copy duly attested.
Accident Claim Procedure:
In case of accident benefit claim additional requirements have to be submitted along with the
Death Registration Certificate. This includes:
1. Copy of FIR

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2. Post Mortem Report
3. Police Inquest Report
4. Police Conclusion Report / Final Report of Police.
Scholarship Claim Procedure:
The member of Aam Aadmi Bima Yojana whose child is eligible for this scholarship has to
fill up an application form every half a year and submit it to the Nodal Agency.
1. The Nodal Agency will have to identify and then verify the students.
2. The Nodal Agency official then would submit the list of beneficiary students to the
concerned P&GS unit with full details which include:
 Name of the student
 School’s name
 Class
 Member’s name
 Master policy no.
 Membership no.
 NEFT details for direct payment.
3. Each half year, on July 1 and January 1, LIC will credit the scholarship payment to
the Account of the beneficiary student, by NEFT or bank account, if the NEFT facility is
unavailable.

[Link] -AYUSHMAN BHARAT YOJANA

Ayushman Bharat Yojana, also known as the Pradhan Mantri Jan Arogya Yojana (PMJAY),
is a scheme that aims to help economically vulnerable Indians who are in need of healthcare
facilities.

Prime Minister Narendra Modi rolled out this health insurance scheme on 23 September 2018
to cover about 50 crore citizens in india and already has several success stories to its credit.
As of September 2019, it was reported that 18,059 hospitals have been empanelled, over
4,406,461 lakh beneficiaries have been admitted and over 10 crore e-cards have been issued.

The Ayushman Bharat Yojana - National Health Protection Scheme, which has now been
renamed as Pradhan Mantri Jan Arogya Yojana, plans to make secondary and tertiary
healthcare completely cashless. The PM Jan Arogya Yojana beneficiaries get an e-card that
can be used to avail services at an empanelled hospital, public or private, anywhere in the
country. With it, you can walk into a hospital and obtain cashless treatment.

The coverage includes 3 days of pre-hospitalisation and 15 days of post-hospitalisation

expenses. Moreover, around 1,400 procedures with all related costs like OT expenses are
taken care of. All in all, PMJAY and the e-card provide a coverage of Rs. 5 lakh per family,
per year, thus helping the economically disadvantaged obtain easy access to healthcare
services.
PMJAY HEALTH COVER CATEGORIES: ELIGIBILITY CRITERIA FOR RURAL &
URBAN PEOPLE
The PMJAY scheme aims to provide healthcare to 10 crore families, who are mostly poor
and have lower middle income, through a health insurance scheme providing a cover of Rs. 5

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 lakh per family. The 10 crore families comprise 8 crore families in rural areas and 2.33 crore
families in urban areas. Broken into smaller units, this means the scheme will aim to cater to
50 crore individualbeneficiaries.

PMJAY Rural:
The 71st round of the National Sample Survey Organisation reveals that a staggering 85.9%
of rural households do not have access to any healthcare insurance or assurance.
Additionally, 24% of rural families access healthcare facilities by borrowing money.
PMJAY’s aim is to help this sector avoid debt traps and avail services by providing yearly
assistance of up to Rs. 5 lakh per family. The scheme will come to the aid of economically
disadvantaged families as per data in the Socio-Economic Caste Census 2011. Here too,
households enrolled under the Rashtriya Swasthya Bima Yojana (RSBY) will come under the
ambit of the PM Jan Arogya Yojana.

In the rural areas, the PMJAY health cover is available to:

 1) Those living in scheduled caste and scheduled tribe households
 2) Families with no male member aged 16 to 59 years
 3) Beggars and those surviving on alms
 4) Families with no individuals aged between 16 and 59 years
 5) Families having at least one physically challenged member and no able-bodied
adult member
 6) Landless households who make a living by working as casual manual labourers
 7) Primitive tribal communities
 8) Legally released bonded labourers
 9) Families living in one-room makeshift houses with no proper walls or roof
 10) Manual scavenger families

PMJAY Urban:
According to the National Sample Survey Organisation (71st round), 82% of urban
households do not have access to healthcare insurance or assurance. Further, 18% of Indians
in urban areas have addressed healthcare expenses by borrowing money in one form or the
other. Pradhan Mantri Jan Arogya Yojana helps these households avail healthcare services by
providing funding of up to Rs. 5 lakh per family, per year. PMJAY will benefit urban
workers’ families in the occupational category present as per the Socio-Economic Caste
Census 2011. Further, any family enrolled under the Rashtriya Swasthaya Bima Yojana will
benefit from the PM Jan Arogya Yojana as well.

In the urban areas, those who can avail of the government-sponsored scheme consist
mainly of:
 1. Washerman / chowkidars
 2. Rag pickers
 3. Mechanics, electricians, repair workers
 4. Domestic help
 5. Sanitation workers, gardeners, sweepers
 6. Home-based artisans or handicraft workers, tailors
 7. Cobblers, hawkers and others providing services by working on streets or
pavements

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 8. Plumbers, masons, construction workers, porters, welders, painters and security
guards
 9. Transport workers like drivers, conductors, helpers, cart or rickshaw pullers
 10. Assistants, peons in small establishments, delivery boys, shopkeepers and waiters

People not entitled for the Health Cover under Pradhan Mantri Jan Arogya Yojana:
 1. Those who own a two, three or four-wheeler or a motorised fishing boat
 2. Those who own mechanised farming equipment
 3. Those who have Kisan cards with a credit limit of Rs.50000
 4. Those employed by the government
 5. Those who work in government-managed non-agricultural enterprises
 6. Those earning a monthly income above Rs.10000
 7. Those owning refrigerators and landlines
 8. Those with decent, solidly built houses
 9. Those owning 5 acres or more of agricultural land

MEDICAL PACKAGES AND HOSPITALIZATION PROCESS IN AYUSHMAN

BHARAT SCHEME (PMJAY)
The Rs. 5 lakh insurance cover provided by the Pradhan Mantri Jan Arogya scheme can be
utilized not just by individuals in particular, but also by families in general. This lumpsum is
enough to cover both the medical and surgical treatments in 25 specialities among which are
cardiology, neurosurgery, oncology, paediatrics, orthopaedics, etc. However, medical and
surgicalexpensescannotbereimbursedsimultaneously.

If multiple surgeries are necessary, the highest package cost is paid for in the first instance
followed by a 50% waiver for the second and a 25% discount for the third. Unlike other
health insurance schemes, there is no waiting period for pre-existing diseases under PMJAY
scheme, which comes under the larger umbrella scheme of Ayushman Bharat Yojana. Should
any beneficiary or anyone in their family require hospitalization, they need not pay anything,
provided they are admitted in any empanelled government or private hospital.

PMJAY helps households access secondary and tertiary care via funding of up to Rs. 5 lakh
per family, per year. This assistance is valid for day care procedures and even applies to pre-
existing conditions. PMJAY extends coverage for over 1,350 medical packages at
empanelled public and private hospitals.

Some of the Critical illnesses that are covered are as follows.

 Prostate cancer
 Coronary artery bypass grafting
 Double valve replacement
 Carotid angioplasty with stent
 Pulmonary valve replacement
 Skull base surgery
 Laryngopharyngectomy with gastric pull-up
 Anterior spine fixation
 Tissue expander for disfigurement following burns

PMJAY has a minimal list of exclusions. They are as follows.

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 OPD
 Drug rehabilitation programme
 Cosmetic related procedures
 Fertility related procedures
 Organ transplants
 Individual diagnostics (for evaluation)

SUMMARY

Health insurance, like other forms of insurance, is a form of collectivism by means of which
people collectively pool their risk, in this case the risk of incurring medical expenses.”,to
increase the access to health care and to protect the employees from high medical expenses at
the time of illness. The two mandatory government run schemes includes-Central
Government Health Schemes (CGHS) and Employee’s state insurance scheme (ESIS)The
Government of India has brought out several Health schemes that are run for the health
benefits of the common man. Like Rashtriya Swasthiya Bima Yojana (RSBY),Aam Aadmi
Bima Yojana (AABY) and Janashree Bima Yojana (JBY) .
CONCLUSION
A class on health schemes and insurances is beneficial for the masters of community health
nursing students to know about the various health schemes running by the government of
India and the benefits that these schemes or insurances are provided to their beneficiaries.
BIBLIOGRAPHY
 [Link]
 [Link]
 [Link]
 [Link]
 [Link]
 [Link]
pmjay-scheme

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 RAJKUMARI AMRIT KAUR COLLEGE OF
NURSING

MATERIAL ON
HEALTH SCHEMES AND
INSURANCE

SUBMITTED TO SUBMITTED BY
MADAM SARITA SHOKANDA MS. DIVYA KHATRI
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SENIOR TUTOR MSC NURSING, 3RD SEM

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