Last updated: June 25th, 2019 2:11 AM

Universal Health Insurance Scheme (UHIS)

To enjoy and strive in good health is one of the fundamental rights of every citizen. Therefore, the Government of India aims to provide proper medical care for a very nominal cost, or even free, to protect the health of its citizens. Under the Univeral Health Assurance Mission (UHAM), the Universal Health Insurance Scheme (UHIS) was introduced by the Ministry of Health and Family Welfare. The scheme covers medical expenses, offers personal accident covers to the primary income-earner of a family, and provides compensation to families if they pass away. This Scheme may be availed by both, Above Poverty Line (APL) and Below Poverty Line (BPL) families as well. This article talks about the various essential aspects of the Universal Health Insurance Scheme (UHIS).

Eligibility

The eligibility for the UHIS is mostly based on the fact if the individual or the family is above or below the poverty line. The following are the features listed for both.

Eligibility for APL

The income of the family is expected to be over a particular amount, making them eligible for the Scheme. The insurance scheme may be availed by individuals between the ages of 5 to 65 years. Children and infants of any age between 3 months to 5 years may be covered under the Scheme as long as both the parents are covered under the same subsequently.

Eligibility for BPL

The income of the family is expected to be less than a particular amount, making them eligible for the Scheme. A certificate issued by an official ( an official with a rank not less than the rank of a BDO/ Tehsildar of the Revenue Department of the relevant State) has to be submitted. The insurance scheme may be availed by individuals between the ages of 5 to 70 years. Children and infants of any age between 3 months to 5 years may be covered under the Scheme as long as both the parents are covered under the same subsequently.

Salient Features

The features of the UHIS are mostly based on the fact if the individual or the family is above or below the poverty line. The following are the features listed for both.

Features for APL families/ individuals

The following are the features by the UHIS for families or individuals in the Above Poverty Line category.

1. The UHIS is accessible for groups. It is available for families/ groups that comprise of more than 100 families. The eligible members for each of these families under the insurance will be covered, i.e. insured individuals under a single group policy only. Therefore, eligible members of different categories will not be allowed for insurance coverage under different group insurance policies. Hence, it is not permitted for any unnamed group insurance policy to be issued.
2. The UHIS is issued in the name of a Group/ Institution / Association with a list of names of their members which also includes their eligible family members, who will also be insured under the policy.
3. This Scheme offers coverage in the form of the following:
   • Reimbursements for medical treatments
   • Hospitalisation expenses for diseases or illnesses that may have been contracted.
   • Hospitalisation expenses for any injuries.

Features for BPL families/ individuals

The following are the features by the UHIS for families or individuals in the Below Poverty Line category.

1. The UHIS may be availed to both individuals, as well as in groups, similar to that offered for APL families and individuals.
2. Every member who is insured under the Scheme is covered under one group insurance policy only.
3. An individual UHIS Policy will be issued in the name of the person who is the income-earner of the family. For groups, the insurance policy will be issued in the name of the group/ institution/ association with a list of names of its members that should include their eligible family members forming a part of the UHIS policy.

UHIS Coverage and Benefits

The coverage and benefits of the UHIS are mostly based on the fact if the individual or the family is above or below the poverty line. The following are the benefits and the coverage for both groups specifically.

Coverage and Benefits for APL families/ individuals

It should be noted that the total expenses incurred for any single illness are restricted to a maximum of INR 15,000. Moreover, the liability of the insurance company in terms of claims admitted during the period of insurance shall not cross the sum insured threshold of INR 30,000 per individual or family.

1. The UHIS covers up to 0.5% of the sum insured per day for Room Expenses as offered by the Hospital/ Nursing Home.
2. If an insured individual is admitted in the Intensive Care Unit/ICU, up to 1% of the sum insured per day may be claimed.
3. Expenses incurred for experts such as Surgeons, Anaesthetists, Medical Practitioners, Consultants and fees such as Specialists Fees or Nursing Expenses, reimbursement of up to 15% of the sum insured per injury or illness may be claimed.
4. Other expenses that include the cost of Anaesthesia, Blood, Oxygen, Operation Theatre, Surgical Instruments and Appliances, Medicines, Drugs, Diagnostic Material and X-Ray, Dialysis, Chemotherapy, Radiotherapy, Pacemaker, Artificial Limbs may be reimbursed with a maximum limit of 15% of the sum insured per injury or illness.

Coverage and Benefits for BPL families/ individuals

For families or individuals who fall in the BPL category, the UHIS offers either healthcare or hospitalisation benefits along with Death through Accident benefits of the income-earner.

Hospitalisation Coverage/ Benefits

Every hospitalisation benefits and the coverage offered to individuals or families in the Above Poverty Line category would be provided to the individuals or families in the Below Poverty Line category.

Maternity Benefits

The UHIS offers an amount of INR 2,500 for women who undergo a standard delivery and INR 5,000 for women who undergo a caesarean delivery. However, a waiting period of 1 year from the inception of the UHIS Policy is applicable. The amount would also cover medical expenses incurred up to 3 months in respect of a newborn child. However, the maternity benefits have to stay within the overall limit of INR 30,000.

Accident Cover

The UHIS Policy offers INR 25,000 to the Insured under the following conditions:

• The Insured is the income-earning head of the family
• If the Insured sustains any bodily injury as a result of an accident or directly from an accident only.
• If the injury causes the death of the Insured within 6 months (unless otherwise specified).

Disability Compensations

For disability compensations, the maximum liability of the insurance company is limited to INR 750 during the UHIS policy period. If the income earning head of the family or their Spouse is hospitalised due to an accident/ disease/ illness, the family will receive a compensation of INR 50 per day from the 4th day of hospitalisation to a maximum of 15 days, as per policy period. Therefore, a valid claim must be submitted under Section 1 of the Policy and waiting period of 3 days is applicable.

Premium Payment

The premium payment of the UHIS is based on the fact if the individual or the family is above or below the poverty line. The following is the premium payment rates for both groups specifically.

Above Poverty Line Individuals/ Families

• The premium for an Individual is estimated to be  INR 365 per annum.
• For Families with equal to or less than 5 members (comprising of the Insured, their Spouse and their first 3 dependent children), the premium amount would be INR 548 per annum.
• For Families with more than 5 members (comprising of the Insured, their Spouse, their first 3 dependent children and their dependent parents), the premium amount would be INR 730 per annum.

Risk Period	Rate of Premium Amount
Up to 1 month	1/4 of the Annual Rate
Up to 3 months	1/2 of the Annual Rate
Up to 6 months	3/4 of the Annual Rate
More than 6 months	Full Annual Rate

Below Poverty Line Individuals/ Families

The following are the Premium Amount, Share of the Insured and the Subsidy from the Government for the Scheme for Below Poverty Line Families and Individuals.

Coverage	Premium	Insured's share	Subsidy
Individual	INR 300	INR 100	INR 200
Family with up to 5 Members	INR 450	INR 150	INR 300
Family with up to 7 Members	INR 600	INR 200	INR 400

Note: Premiums for the Scheme may vary depending on various factors such as Age, Location, GST and other governing taxes.