Rashtriya Swasthya Bima Yojana (RSBY), which is the health insurance scheme for the Below Poverty Line (BPL) families in India is running into issues due to delay in payment of premiums by the Government and the delay in claims processing by the Health Insurance companies.
The salient features of RSBY are:
1. It aims to provide health coverage to BPL families who cannot afford to pay for health related expenditures. It is a nationwide scheme.
2.It has been rolled out by the Ministry of Labour. Each beneficiary is entitled to a health insurance coverage of Rs 30,000. It is effectively free for the policyholder with them needing to pay only Rs 30 to get enrolled in the scheme
3. There is no age limit and most pre existing diseases are covered
4. 25% of the health insurance premium is paid by the State Government and and 75% of the health insurance premium is paid by the Central Government
5. The policyholder has a choice of public or private hospitals. SmartCards are issued to the policyholder and the smartcard can be used in any RSBY empanelled hospital in the country. In that sense, there is no locational constraint.
6. The policyholder is entitled to cashless claims
5. 2.5 crore smart cards have been issued across 25 states
But of late, the government and the insurers have started pointing fingers at each other regarding premium payment and health claims payment. Rs 225 crores worth of premium which has to be paid by the State Government is now pending. The Central Govt has cleared its part of the premium payment obligation. Because the take up rate of the scheme has increased very rapidly, state governments have been struggling to keep up with their obligation towards the premium payment.
On the other hand, the government has expressed concern at the high level of claims pending with the insurers. While there has definitely been a great deal of fraudulent claims, the pending claims ratio is still way too high. The four public health insurers are yet to settle 50% of the claims. ICICI Lombard has 35% claims pending while Tata AIG has 28% claims outstanding.Mr Anil Swarup, joint secretary in the Labour ministry, has gone on record saying that the four nationalised general insurance companies have been very slow in the processing of health insurance related claims under RSBY.The official guideline in RSBY is that claims have to be settled under 21 days.The private insurance companies and the 4 public general insurance companies have exactly 50% market share under RSBY.