Swasthya Sathi: A major welfare step towards healthy Bengal

The Swasthya Sathi health insurance scheme had been introduced by the Government of West Bengal on 30th December, 2016, much before a similar scheme was introduced by the Central Government Ayushman Bharat (Pradhan Mantri Jan Arogya Yojana) (PMJAY).

Initially Swasthya Sathi was a scheme for a specified and targeted population-group. After the State Government decided to continue with this scheme and not to opt for the Central Scheme, Swasthya Sathi has now been extended to the entire resident population of the State from December 1, 2020. This is a major welfare step, especially at the time of this ongoing pandemic.

What is Swasthya Sathi?

It is a comprehensive and free family-floater health cover for secondary and tertiary medical care up to Rs. 5 lakh per annum. The treatment must entail hospitalization. A wide variety of surgical and non-surgical procedures are covered. There is no cap on the family size and the parents of both the spouses are eligible for coverage. All dependent and physically challenged persons in the family can also be covered. A Smart Card is issued to each family which enables cashless hospitalization. The Smart Card captures the details of the family members such as photographs, biometric data, address, mobile number and SECC (Socio-Economic Caste Census) ID.

The Smart Card has to be presented by the patient at the time of hospitalization. A robust IT platform and a paperless interface are other hallmarks of the Scheme.

What is meant by cashless service?

Cashless service means that the patient will not have to spend any amount from his pocket for hospitalization and treatment at an empanelled hospital.

What is meant by floater cover?

Floater cover means that the entire family enrolled in the scheme has a maximum and specified amount of Rs 5 lakhs at their disposal for treatment by hospitalization in an empanelled hospital. Any member of the family can be treated, even simultaneously, as long as the total amount is within the annual ceiling of Rs 5 lakhs.

What is meant by hospitalization?

Hospitalization means admission to an empanelled hospital for 24 hours or more. However, it also includes such day care treatments entailing less than 24 hours, as are listed out. There are approximately 245 numbers of Daycare packages under this scheme.

What do the beneficiaries have to pay?

The scheme is fully funded by the Government of West Bengal. No payment is charged to the beneficiary for this scheme.

What are its unique features?

It is totally free for all beneficiaries. All pre-existing diseases are covered from day one. As there is no waiting period for hospitalization, the beneficiary can be hospitalized, immediately after enrolment, for a pre-existing disease, if so required.

There is no upper limit on age of enrolment. Hence, all aged members of the family will also get the benefit of coverage. No aged person will be excluded on the basis of his/her age.

Women's empowerment is also an objective of the scheme. The enrolment card is issued to the eldest female member of the family. Both her parents and in-laws will also be covered along with the other family members.

Are pre and post hospitalisation expenses covered?

Yes. Pre-hospitalization expenses are such expenses as are incurred by the hospitals before taking a view with regards to hospitalization. Expenditure incurred by the beneficiary on tests/ medicines which lead to hospitalization is also covered for reimbursement subject to production of proof.

Post-hospitalization expenses are covered till 5 days of discharge from the hospital. The hospital will provide medicines and other assistance which is needed for the patient till five days after discharge from the hospital.

What are package charges?

A package charge means that all the expenses related to the treatment like medicines, tests, bed charges, other materials, food etc. will be part of package and hospital will not charge anything from the patient. Approximately, 2092 packages are available. However, all packages are not available in all hospitals.

Are maternity procedures/expenses covered?

Yes. Both normal and caesarean section delivery charges are covered in the listed packages.

Are cataract operations and critical illnesses like cancer, heart treatment and dialysis and transplants covered?

Yes

Is OPD treatment covered?

No. OPD treatment is not covered in isolation. However, if it subsequently leads to hospitalization, then it will be covered, as part of pre-hospitalization expenses.

Is transport allowance payable?

Yes. It is limited to Rs. 200/- only per hospitalization and Rs. 2000/- in a policy year. However if the treatment is done  in any Government Hospital through Swasthya Sathi card additional transport allowance is provided and beneficiary will get Rs 400/- to Rs 700/- as Transport allowance.

What is the process of enrolment?

The applicant has to show documents like Aadhar Card, Voter ID and /or Digital Ration Card and fill in an Application Form for this purpose. After submission of the Application Form, the beneficiary gets a SMS with ID-District Code/Serial number. A Unique Registration Number or URN is generated and the Smart Card is delivered within a week. Additions/deletions/corrections are done at District kiosks. Enrolment of applicants will also take place at the State Government organized outreach programmes and camps referred to as "Duare Sarkar" or Government at Your Door-step. Mop-up Camps will also be organised for further enrolments.

Who are the current beneficiaries?

Indian citizens who are ordinarily resident in the State of West Bengal are eligible for coverage.

Who are not eligible for coverage?

Neither those families whose member/s are already receiving benefits under a Government-sponsored Health Insurance/Assurance Scheme nor families which have a member or members already receiving Medical Allowance from the Government are eligible for coverage. The Application Form contains a declaration to this effect which the applicant has to sign.

What are the other important features?

24 X 7 toll free Call Centre (18003455384) with feedback option

Android based Swasthya Sathi Mobile app for assistance to the beneficiaries

Online grievance monitoring Mechanism

Have private hospitals also been empanelled for treatment?

Medical Colleges and Government hospitals as well as private hospitals are empanelled for treatment according to certain parameters. Empanelled hospitals are spread across all parts of West Bengal. There are now approximately 1,590 hospitals in the state, empanelled in this scheme. Christian Medical College, Vellore, Tamil Nadu has also been empanelled for treatment.

What is the intended number to be covered?

Around 1.5 crore families will be covered under the scheme, which will include approximately 7.5 crore people

What is cost of this scheme to the exchequer?

The annual expense which the State is going to bear for this scheme will be approximately Rs 2,000 crore.