The Swasthya Sathi Scheme was launched in December 2016 by the government of West Bengal to provide basic health insurance cover for families. The scheme was later merged with Prime Minister, Narendra Modi’s flagship health insurance plan ‘Ayushman Bharat’. Both plans came to collectively be called ‘Swasthya Sathi’ in West Bengal. The scheme aims to offer one medical insurance plan to the people of West Bengal particularly to informal contractual workers in the government department and other people living below the deprivation limit. The health insurance cover can be extended to provide financial protection to the family members including spouse, children and parents.

Scope of the Swasthya Sathi Scheme

The Swasthya Sathi Scheme initially covered 47 lakh beneficiaries in the state of West Bengal. However, in 2018, the plan included 6 crores, individuals. Moreover, the policy only offered insurance cover of Rs. 1.5 lakh earlier, whereas after the merger, the scheme now provides insurance coverage of Rs 5 lakhs. The expense, for the common beneficiaries of the state and the centre, will be shared between the centre and the state government.

Main Features of the Swasthya Sathi Scheme

Some of the main features of the Swasthya Sathi Scheme include:

  • The policy is a standard health insurance plan offering secondary and tertiary care of Rs. 5 lakh per annum per insured family.
  • It is a paperless, hassle-free, cashless and a completely smart card-based scheme.
  • The policy provides protection against all pre-existing medical conditions.
  • There is no upper limit on the size of the family. Moreover, the insurance cover can be extended to include both spouse parents.
  • The scheme also offers cover for any physically dependent or challenged persons in the family of the insured.
  • The policy offers benefits like pre-and post-hospitalisation costs, transport, medications, IPD, OPD consultation, etc.
  • The total insurance premiums under the scheme are paid by the State and the Centre government, with no contribution from the beneficiary.
  • The scheme offers an online Swasthya Sathi Smart card for each family. The card is given on the day of enrolment. It includes all details of the family members, their photographs, biometrics, addresses, mobile numbers, and SECC ID.
  • The insurance plan is completely paperless and is managed through a robust IT platform.
  • The scheme also promotes informed decision making by providing online empanelment and gradation of hospitals in accordance with their services and infrastructure.
  • The insurance plan allows 100% pre-authorisation online. The turn-around time is 24 Hrs.
  • The scheme sends authorised SMS and instant alerts in case of blocking or misuse of the card.
  • The management panel uploads all e-health records of the beneficiaries on discharge in real-time.
  • The insurance plan includes hospital claim reimbursement with a tentative timeline of 30 days. Failure or delayed payments will lead to a charge of interest.
  • You can seek query resolution or any assistance from the 24X7 toll-free call centre. You can also give feedback about the scheme on the toll-free number available on the website.
  • The Swasthya Sathi Scheme includes an online complaint monitoring mechanism.
  • The policy sends online triggers and specific alarms in case of probable frauds with escalation matrix.
  • The insurance plan offers Android-based Swasthya Sathi Mobile app for beneficiary assistance.

Hospitals covered under Swasthya Sathi Scheme

The list of network hospitals where cashless treatment is offered by the Swasthya Sathi Scheme is given at the time of issuance of the Smart Card. In case of any information related to the network hospital, you can call the free toll helpline number, which is mentioned at the back of the Smart insurance card. Alternatively, you can use the Mobile App to find a hospital in the ‘active hospital tab’ option. Lastly, the list is also available on https://swasthyasathi.gov.in.

Generally, the hospitals are selected according to their facilities and infrastructure services. These hospitals are then rated according to grades – Grade A, Grade B, Grade C and Grade R. Grade A being the most preferred choice. The selection or list of network hospitals comprises both public and private hospitals.

Overall, the Swasthya Sathi Scheme was launched to increase the penetration of insurance in those who are less privileged. With the rising medical costs coupled with an increase in the intrinsic and extrinsic risk factors, insurance plans like Swasthya Sathi Scheme, act as a blessing for people, especially those who are below the deprivation level and cannot afford an insurance cover.

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