For years, the Indian government has been actively working to improve healthcare access across the country. Despite numerous initiatives from the Insurance Regulatory and Development Authority of India (IRDAI) and efforts to promote the importance of health insurance, many Indians still lack coverage. The reasons are clear: the limited accessibility of health insurance in remote areas, lack of awareness about the financial security offered by health insurance, and the widespread belief that health insurance is unaffordable, especially for those living below the poverty line.
This is why various central and state governments have introduced several health insurance schemes over the years. These schemes aim to make healthcare more affordable and ensure that healthcare is within reach for all citizens.
So, in today’s article, let’s explore some government health insurance schemes and how they fare against some of the top private health insurance plans.
What is a Government Health Insurance Scheme?
Government health insurance schemes are state-sponsored programs that provide health insurance coverage to specific groups, especially economically weaker sections, government employees, or workers in certain industries.
Why are Government Health Insurance policies required?
Government Health Insurance schemes aim to make healthcare affordable and accessible to all citizens, ensuring that no one is denied necessary medical treatment due to financial constraints.
As with any other health insurance policy, it provides a safety net. However, unlike many standard health insurance policies, the government mainly provides it for the most vulnerable populations, ensuring they have access to essential healthcare services.
According to research by the Public Health Foundation of India, approximately 55 million people were pushed into poverty from 1994 to 2014 because of out-of-pocket healthcare expenditures. This is especially true for the lower-income segment of the population.
Government health insurance schemes help reduce the financial burden on individuals and families, which eventually prevents them from falling into poverty (at least) due to high medical expenses.
While this might sound similar to a regular health insurance plan, there are some key differences between the two. Let’s explore them now.
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What is the difference between Standard Health Insurance Plans and Government Health Insurance Schemes?
Private insurance companies often offer standard health insurance plans with comprehensive coverage and additional benefits like cashless claim settlement, higher cover amounts, and extensive network hospital lists. However, these plans are usually expensive, and not everyone can afford them.
On the other hand, government health insurance schemes are subsidized or free and designed to cover essential healthcare services. They might have lower sum insured limits and fewer benefits compared to private plans, but they offer basic insurance coverage to those who need it the most.
Here are some differences summarised:
| Basis | Government Health Insurance Policies | Standard Health Insurance Policies |
|---|---|---|
| Premiums | Generally free or highly subsidized | Premiums can be expensive |
| Target Audience | Economically weaker sections, vulnerable groups | Middle to upper-income groups |
| Coverage | Basic healthcare services, essential treatments | Comprehensive coverage, optional add-ons, and extensive benefits |
| Sum Insured | Usually lower than private insurers | Higher sum insured options available |
| Provider | Central or State Governments | Private/Public Insurance Companies |
| Network Hospitals | Often includes public hospitals only | Includes a wide range of private hospitals |
That said, here are some health insurance schemes that various State Governments and the Central Government of India provide.
What are the Top Government Health Insurance Schemes available in 2024?
The government offers various health insurance schemes to different segments of the population. Here are some of the top government health insurance schemes available in 2024:
Central Government Schemes:
- Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PM-JAY):
- Aimed at the bottom 40% of the population based on income.
- Coverage: Up to INR 5 lakhs, including 3 days of pre-hospitalisation and 15 days of post-hospitalisation.
- Benefits: The funding offered is capped at INR 5 lakhs and covers 3 days of hospitalisation charges and 15 days of post-hospitalisation charges. The plan offers to fund all pre-existing ailments and demands no waiting period. Policyholders can enjoy the perks of cashless treatment at network hospitals and additional coverage for ICU charges, doctor’s fees, prescription medicines, and more. The annual premium for this policy is INR 30.
2. Employees' State Insurance Scheme (ESI):
- This is for workers with monthly wages up to INR 21,000 (INR 25,000 for those with disabilities).
- Coverage: Jointly funded by employer and employee, covering medical expenses, sickness benefits, and disability benefits.
- Benefits: The plan usually calls for an equal part payment towards the premium of the plan by the employer and the employee (except in the case of workers earning less than INR 137/day, in which case the employer pays the entire premium). The plan is extended to the employee and his/her family and offers a sickness benefit of up to 91 days/year and an extended sickness benefit of up to 2 years in the case of malignant or long-term ailments. This govt health insurance also offers a disablement benefit, a 26-week maternity benefit, and a dependents’ benefit due to workplace hazards.
3. Pradhan Mantri Suraksha Bima Yojana (PMSBY):
- Provides funds in case of accidental disability or death.
- Coverage: INR 2 lakhs for complete disability or death, INR 1 lakh for partial disability.
- Benefits: The plan offers a sum insured of INR 2 lakhs in the case of accidental complete disability or death and INR 1 lakh in the case of partial disability. All that the policyholder needs is their Aadhar Card and a bank account from where the premium for Pradhan Mantri Suraksha Bima Yojana (PMSBY) will be automatically deducted.
4. Rashtriya Swasthya Bima Yojana (RSBY):
- For workers in unorganised sectors.
- Coverage: INR 30,000 per family per year.
- Benefits: The plan offers INR 30k for workers and their families and covers the expenses involved in hospitalisation, treatment of pre-existing ailments, and transportation expenses (capped at INR 1k). At a premium of INR 30/year, the plan offers cashless benefits, too.
5. Janani Suraksha Yojana:
- Ensures healthy pregnancy treatments for economically disadvantaged women.
- Coverage: Free treatment and cash assistance for delivery and post-delivery care.
- Benefits: This plan’s coverage includes funding required for the delivery process and post-delivery care assistance. Policyholders receive completely free treatment in Government medical facilities along with some cash assistance (INR 2000 or INR 700 for the Low Performing States and INR 1200 or INR 600 for the High Performing States, depending on whether they are located in rural or urban areas).
6. Universal Health Insurance Scheme (UHIS):
- Family floater plan for economically disabled families.
- Coverage: INR 30,000 for medical expenses and INR 25,000 for accidental death.
- Benefits: This government mediclaim policy is one that funds the medical expenses for the entire family up to INR 30k. This funding caters to the expenses incurred in cases of doctor’s consultation fees, hospitalisation, maternity, room rent, and medical supplies. The policy also offers a cover of up to INR 25k for accidental death.
| Central Government Scheme | Eligibility | How to Enrol |
|---|---|---|
| Ayushman Bharat | EWS | |
| CGHS | Central Govt. Employees, Central Govt. Pensioners and their families. | |
| RSBY | Household income below the poverty line. | |
| ESI | Employees earning less than ₹2.5 lakhs per annum. | |
| JSY | Economically challenged pregnant women and children. | |
| UHIS | Families that are economically challenged. |
State Government Schemes:
- Maharashtra - The Mahatma Jyotiba Phule Jan Arogya Yojana
- Definition: Health insurance for those living below the poverty line.
- Coverage: Covers the entire family with INR 2.5 lakhs for renal transplants and INR 1.5 lakhs for hospitalisation expenses.
2. Rajasthan - The Bhamashah Swasthya Bima Yojana
- Definition: Intended for the rural population and beneficiaries under the National Food Security Act.
- Coverage: It covers pre- and post-hospitalisation, critical ailments up to INR 3 lakhs, and general illnesses up to INR 30,000. It also offers cashless treatment and OPD coverage.
3. Tamil Nadu - Chief Minister’s Comprehensive Insurance Scheme
- Definition: Family floater policy for individuals with an annual income of less than INR 75,000.
- Coverage: Provides up to INR 5 lakhs for hospitalisation expenses and covers 1000+ medical procedures in both private and public healthcare facilities.
4. West Bengal - West Bengal Health Scheme
- Definition: Offered to government employees and pensioners.
- Coverage: Individual or family floater policy with a sum insured up to INR 1 lakh. Covers OPD treatments and medical surgeries.
5. Karnataka - Yeshasvini Health Insurance Scheme
- Definition: Aimed at peasants and farmers for access to quality healthcare.
- Coverage: Covers funding for 823 surgical procedures across 600 network hospitals for individuals under 75 years of age.
6. Gujarat - Mukhyamantri Amrutam Yojana
- Definition: Family floater policy for the economically disadvantaged.
- Coverage: The sum insured is up to INR 3 lakhs for medical treatments in trust-based, public, and private hospitals.
7. Kerala - Karunya Health Scheme
- Definition: Critical illness cover for the economically backward population (annual income < INR 3 lakhs).
- Coverage: Covers up to INR 5 lakhs for critical ailments, secondary and tertiary hospitalisation care, including surgery, ICU, medicines, and diagnostics.
8. Andhra Pradesh - Dr YSR Aarogyasri Health Care Trust
- Definition: Includes various schemes for different economic segments.
- Coverage: Up to INR 5 lakhs per annum for family. Covers hospitalisation, pre-existing conditions, follow-up treatments, and outpatient care.
9. Telangana - Telangana State Government Employees and Journalists Health Scheme
- Definition: For government employees and journalists.
- Coverage: No upper limit on the sum insured. Covers retired, current, and pensioner employees without any contributions needed from them.
Top Private Health Insurance Policies in India
While government health insurance schemes offer essential coverage, standard health insurance policies provided by private insurers often come with additional benefits and more comprehensive coverage. It is always recommended that you purchase a good health insurance policy. Here are some top standard health insurance policies to consider:
| Top Health Insurance Pan | Waiting Periods | Other features | Insurer Metrics |
|---|---|---|---|
| Aditya Birla Activ One Max | |||
| HDFC ERGO Optima Secure | |||
| Care Supreme | |||
| Niva Bupa ReAssure 2.0 |
Things to Keep in Mind when Availing of a Government Health Insurance Policy
- Hospital Coverage: Government schemes primarily cover treatments in public hospitals, but many also have tie-ups with private hospitals. For example, PM-JAY has a network of both public and private hospitals. Check the scheme’s network list for specific details.
- Coverage Eligibility: Coverage under schemes like ESIC and CGHS is usually linked to your employment status or specific region. You need to update your details with the respective scheme to ensure continuous coverage. For schemes like PM-JAY and RSBY, coverage is usually more flexible and transferable.
- Pre-existing Conditions: Coverage for pre-existing conditions varies by scheme. For example, PM-JAY covers pre-existing conditions from the start, while other schemes may have specific waiting periods or exclusions.
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Conclusion
Government health insurance schemes ensure that even the most vulnerable of the populous receive necessary medical treatments without financial turmoil. However, these schemes come with their own set of challenges. While they provide essential coverage, their limitations and bureaucratic processes can sometimes be challenging.
If you can afford it, purchasing a standard health insurance policy can provide more comprehensive coverage and additional benefits, especially for people with pre-existing diseases or for those who require specific healthcare.
It is always important to evaluate your healthcare needs and financial situation carefully and choose a plan that offers the best protection for you and your family.
