Executive Summary:
The Ministry of Health and Family Welfare addressed a question regarding free health insurance for those Below the Poverty Line (BPL). The response detailed the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (ABPMJAY) scheme, its expansions, and efforts to raise health insurance awareness. ABPMJAY provides health cover of ₹5 lakh per family per year for secondary and tertiary care hospitalization.
Key Points / Main Content:
ABPMJAY Scheme:
* Provides ₹5 lakh health cover per family per year for secondary and tertiary care.
* Covers 12 crore economically vulnerable families (bottom 40% of India's population).
* Expanded in March 2024 to include 37 lakh ASHAs, AWWs, AWHs, and their families.
* Expanded to cover 6 crore senior citizens (70+ years) irrespective of socioeconomic status, through VayVandanacard.
* Offers 1,961 procedures across 27 specialties.
* Fully cashless and paperless.
* Entitlement-based from day one without enrollment.
* Portable benefits across the country.
* No cap on family size, age, or gender.
* Implemented through a three-tier model: National Health Authority, State Health Agencies, and District Implementation Units.
* Funded by the Government with cost-sharing between Centre and States/UTs.
* States/UTs have flexibility in operational models (Insurance, Trust, or Mixed mode).
* Regular updates include new procedures, hospital empanelment, beneficiaries, and improvements.
Insurance Awareness:
* IRDAI mandates insurers to have a board-approved policy for policyholder protection, including insurance awareness mechanisms.
* Insurers must educate prospects and policyholders about insurance products, benefits, rights, and responsibilities.
* Insurers are required to review the policy annually.
* Insurers are mandated to issue a prospectus for every retail product, explaining benefits, features, terms, and conditions, and make it available on their website.
* Frameworks must ensure accurate representation of product features and benefits without misstatement or misrepresentation.
* Well-defined service parameters, turnaround times, and complaint resolution procedures must be in place.
* Insurers must issue a concise and updated Customer Information Sheet (CIS) to policyholders to enhance awareness of policy benefits and terms.
Impact Analysis:
BPL Population/Economically Vulnerable Families:
* Impact: Access to free health insurance up to ₹5 lakh per family per year for secondary and tertiary care.
* Action Required: Awareness and utilization of the ABPMJAY scheme.
ASHAs, AWWs, AWHs, and their Families:
* Impact: Inclusion in the ABPMJAY scheme.
* Action Required: Enrollment and utilization of the scheme.
Senior Citizens (70+ years):
* Impact: Inclusion in the ABPMJAY scheme, irrespective of socioeconomic status.
* Action Required: Enrollment through VayVandanacard and utilization of the scheme.
Insurers:
* Impact: Obligation to have a board-approved policy for policyholder protection and awareness.
* Action Required: Implement and maintain insurance awareness mechanisms, issue prospectuses, ensure accurate product representation, and provide CIS.
IRDAI:
* Impact: Regulatory oversight of insurance awareness and policyholder protection.
* Action Required: Ensure insurers comply with mandated guidelines and policies.
State Health Agencies and District Implementation Units:
* Impact: Operational implementation of ABPMJAY.
* Action Required: Effective implementation of the scheme, including empanelment of hospitals, beneficiary identification, and claim settlement.
Key Entities Referenced
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana ABPMJAY: A flagship scheme of the Government which provides health cover of Rs. 5 lakh per family per year for secondary and tertiary care hospitalization.
Below Poverty Line BPL: Categories of people defined as living below the poverty line, targeted for free health insurance.
Accredited Social Health Activists ASHAs: Community health workers included in the expanded eligibility criteria of ABPMJAY.
Anganwadi Workers AWWs: Childcare and community health workers included in the expanded eligibility criteria of ABPMJAY.
Anganwadi Helpers AWHs: Assistants to Anganwadi Workers, included in the expanded eligibility criteria of ABPMJAY.
Ministry of Health and Family Welfare: The government ministry responsible for health policies and family welfare programs.
Insurance Regulatory and Development Authority of India IRDAI: The regulatory body for the insurance industry in India, responsible for ensuring policyholder protection and promoting insurance awareness.
Ministry of Finance: The government ministry responsible for financial regulations and cost sharing directives between Centre and StatesUTs.
GOVERNMENTOFINDIA
MINISTRYOFHEALTH AND FAMILYWELFARE
DEPARTMENTOFHEALTH ANDFAMILYWELFARE
LOK SABHA
UNSTARREDQUESTION NO. 2087
TOBE ANSWERED ON01STAUGUST,2025
FREE HEALTH INSURANCE TOBPLPEOPLE
2087. SHRIPVMIDHUN REDDY:
Will the Minister of HEALTHAND FAMILYWELFAREbe pleased tostate:
(a) whether the Government is considering any policy measures to provide free health
insurance to categories of people Below Poverty Line (BPL) given that almost 28 percent of
the populationinIndia isbelow the povertyline;
(b) if so, the detailsthereofand if not,the reasons therefor;
(c) whether the Government is raising awareness about health insurance and counteract
misconceptionssurrounding it so that more people maytake it up; and
(d) if so, the detailsthereofand if not,the reasons therefor?
ANSWER
THE MINISTER OFSTATEIN THE MINISTRYOFHEALTHAND
FAMILYWELFARE
(SHRIPRATAPRAOJADHAV)
(a) and (b): Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a
flagship scheme of the Government which provides health cover of Rs. 5 lakh per family per
year for secondary and tertiary care hospitalization to 12 crore families constituting
economicallyvulnerable bottom 40% of India’spopulation.
In March 2024, the eligibility criteria were expanded to include 37 lakh Accredited Social
Health Activists (ASHAs), Anganwadi Workers (AWWs), Anganwadi Helpers (AWHs), and
their families. Recently, the scheme hasbeen expanded tocover 6crore senior citizens of age
70 years and above belonging to 4.5 crore families, irrespective of their socio-economic
status, through VayVandanacard.
The keyfeaturesof AB-PMJAYare asunder:
Provides ₹5 lakh annual health cover per eligible family for 1,961 procedures across
27specialties.
Fullycashless andpaperless. Entitlement-based, coveringall eligiblefamiliesfrom dayone without enrolment.
Benefitsare portable across the country.
No capon familysize, age,or gender.
Implemented through a three-tier model—National Health Authority, State Health
Agencies, andDistrict Implementation Units.
Funded by the Government with cost-sharing between Centre and States/UTs as per
the extantdirectivesissued by Ministry of Finance, from time totime.
States/UTs have flexibilityinoperational models—Insurance, Trust or Mixed mode.
Under AB-PMJAY, regular updation such as inclusion of new procedures,
empanelmentofnewhospitals,inclusionofnewbeneficiariesandotherimprovements
aredoneasperrequirementsfromtimetotime.
(c) and(d): Insurance Regulatoryand Development Authority of India (IRDAI) has informed
that insurers are mandated to have in place a board approved policy for protection of
policyholders’ interests which interalia shall include establishing a mechanism to create
Insurance Awareness on an ongoing basis so as to educate prospects and policyholders about
insurance products, benefits and their rights and responsibilities. The insurers are required to
reviewthe policyannually.
Further, in order toenhance the awareness of the prospects/policyholders about the coverage,
features, benefitsof the products, insurers are mandatedfor the following:
i. toissue theprospectusforeveryretailproduct includingridersor add-ons,explaining
allthe benefits, features, termsandconditionsof the product,andmake availablesuch
prospectus ontheirwebsite.
ii. toputinappropriate frameworktoensurethatthe features, benefitsalongwithterms
and conditions of the products being sold are represented correctly and fully and that
the productsare not mis-stated or misrepresented toprospects or policyholders;
iii. to have in place well defined service parameters, turnaround times, procedure for
expeditious resolution of complaints, steps to prevent mis-selling and un fair business
practice;
iv. to issue of a concise and updated Customer Information Sheet (CIS) to the
policyholders with a view toenhancethe awareness of policyholderabout the benefits
covered,termsandconditionsof the policy.
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