Arogya Sanjeevani Policy

Overview

The Arogya Sanjeevani Policy is a governmentbacked health insurance scheme introduced to provide financial protection against high medical costs for families across the country. Launched in 2023, the policy aims to bridge the gap between rising healthcare expenses and the ability of low and middleincome households to afford quality treatment.

Designed as a universal, portable, and cashless solution, Arogya Sanjeevani enables beneficiaries to access a wide network of empanelled hospitals without paying outofpocket at the point of service. The scheme is part of the broader Health for All mission and aligns with the Sustainable Development Goals related to universal health coverage.

Key Benefits

• Comprehensive coverage: Inpatient, pre and posthospitalisation, daycare procedures, and certain outpatient services.
• No premium for families below the poverty line: The government subsidises 100% of the premium for eligible households.
• Portability: Policy remains valid across the country; members can receive treatment in any empanelled hospital.
• Cashless treatment: Direct settlement between hospital and insurer eliminates the need for upfront payment.
• Annual renewal without medical underwriting: Existing beneficiaries can renew automatically.
• Family floater structure: One premium covers the entire family (up to 5 members).

Eligibility & Enrollment

Eligibility is based primarily on household income and demographic criteria:

• Resident of any state or Union Territory.
• Annual household income up to INR 1,20,000 (subsidised premium) or up to INR 3,00,000 (partial subsidy).
• At least one adult member (1865 years) as the primary enrollee.
• Currently nonbeneficiary of any other centrally sponsored health scheme with overlapping benefits.

Enrollment can be completed through:

• Online portal of the Ministry of Health & Family Welfare.
• Participating banks and post offices (via Aadhar&bank account linking).
• Authorized agents and community health workers.

Required documents include Aadhar card, income proof (ration card, BPL certificate, or salary slip), and proof of residence.

Coverage Details

1. Hospitalisation (Inpatient)

Up to INR 5 lakhs per family per year for room rent, ICU, surgery, medication, diagnostics, and consumables.

2. Pre and PostHospitalisation

Expenses incurred up to 30 days before admission and 60 days after discharge (including physiotherapy and followup visits).

3. Day Care Procedures

All minimally invasive surgeries and procedures that do not require 24hour hospital stay are covered.

4. Maternity & Newborn Care

Normal delivery, caesarean section, newborn vaccination, and essential newborn care up to INR 2 lakhs per pregnancy.

5. Critical Illness Addon (Optional)

Members can purchase an optional rider for an additional premium, extending coverage to critical illnesses such as cancer, heart attack, and kidney failure, with a sum insured up to INR 10 lakhs.

Claims Process

Because the scheme operates on a cashless basis, the process is streamlined:

1. Preauthorization: Present the Arogya Sanjeevani card (or digital QR code) at the hospitals insurance desk.
2. Verification: Hospital submits the treatment plan and estimates to the insurer electronically.
3. Approval: Insurer validates eligibility and approves the cashless claim within 2448 hours.
4. Treatment: Patient receives care; no advance payment required except for noncovered items.
5. Settlement: Hospital invoices the insurer directly; any amount exceeding the policy limit is billed to the patient.

For emergency or outofnetwork situations, a provisional claim can be filed, and the patient receives reimbursement after submitting original documents.

Frequently Asked Questions

Q1: Can I add a new family member after enrollment?

Yes. New members (e.g., newborns) can be added during the annual renewal period without any extra premium for the first year.

Q2: What happens if I switch jobs or move to another state?

The policy is portable. You can continue coverage by updating your address and bank details on the portal. No new medical underwriting is required.

Q3: Are preexisting conditions covered?

All preexisting conditions are covered after a waiting period of 12 months from the date of enrollment, except for the optional critical illness rider, which has its own waiting period.

Q4: How is the premium calculated?

Premium is incomebased and may be fully subsidised for families below the poverty line. For higherincome brackets, a nominal contribution (usually 25% of the sum insured) is required.

Q5: Can I claim expenses for alternative therapies?

No. The scheme covers only allopathic medical treatments approved by the Indian Council of Medical Research (ICMR).