Universal Health Insurance Scheme (UHIS)

With the raging pandemic, the demand for comprehensive health cover has increased. However, there is a fair chunk of people who can’t afford to get health cover.

This was when the government came up with the Universal Health Insurance Scheme (UHIS). In this article, we will learn about UHIS in detail.

What is the Universal Health Insurance Scheme (UHIS)?

The Universal Health Insurance Scheme was inaugurated in 2003 to provide medical coverage to lower-income groups. There are also provisions for accident coverage and compensation in case the breadwinner died.

What are the features of the Universal Health Insurance Scheme?

The UHIS differs based on whether the individual or the group falls Above or Below the Poverty Line.

Universal Health Insurance Scheme features for Above Poverty Line (APL) individuals

This scheme can be availed by both individuals and families who earn above a stipulated amount. The group will need to comprise more than 100 families. All members shall be covered under a single group policy. Lastly, an individual cannot be part of multiple such policies.

The UHIS is issued in the name of a group/institution/association along with a list of names of its members who shall be insured under the policy.

The Universal Health Scheme offers the following as a part of the coverage:

Reimbursements for medical treatments.
Hospitalization expenses for diseases or illnesses that may have been contracted.
Hospitalization expenses for any injuries.

Below Poverty Line (BPL) features

This can be availed by both individuals as well as groups identical to the APL format.

Every member secured under a group can be a part of one group only.

The individual UHIS policy is to be issued to the breadwinner of their family. For groups, insurance is issued on the group's name with a list of names of all members.

What is the benefit offered in the Universal Health Insurance Scheme?

Benefits of UHIS are also variable based on whether the individual/group/association is Below the Poverty Line or not.

Benefits of Universal Health Insurance Scheme for APL

The Universal Health Scheme coverage for APL members include -

The maximum cap on the claim for a single illness is Rs.15,000.
UHIS shall cover 0.5% of the total sum insured on room tariff and boarding expenses as billed by the medical institution.
If an individual is admitted into the Intensive Care Unit (ICU), up to 1% of the insured sum can be claimed.
A total of 15% per illness can be claimed for costs like a surgeon, anesthetist, medical practitioner, consultants, specialists’ fees and nursing expenses.
Costs like anesthesia, blood, oxygen, OT charges, surgical appliances, medicines, diagnostic material & X-ray, dialysis, chemotherapy, radiotherapy, cost of a pacemaker, artificial limbs are covered up to 15% of the sum insured per injury or illness.

Benefits or coverage for BPL

Families falling under the BPL category can either opt for health care or hospitalization benefits and compensation availed at the death of a breadwinner with UHIS.

Hospitalization benefits:

The total expenses incurred for any single illness shall be less than Rs.15000
0.5% of the total sum insured on room tariff and boarding expenses billed by the hospital is up for reimbursement.
If admitted to the ICU, then up to 1% of the sum can be withdrawn per day.
The cost of other medical expenses like a surgeon, anesthetist, medical practitioner, consultants, specialists fees, and nursing expenses and charges like anesthesia, blood, oxygen, OT charges, surgical appliances, drugs, diagnostic material & X-ray, dialysis, chemotherapy, radiotherapy, cost of a pacemaker, artificial limbs are covered up to 15% similar to the APL category.
However, there are added maternity benefits. Rs.2,500 for normal delivery and Rs.5,000 for caesarean delivery for the birth of a single child can be claimed. This amount will also cover the medical expenses of the child for the first three months. However, this benefit is also within the overall sum of Rs.30,000.

Accident cover to the breadwinner

Suppose, the insured, who is also the breadwinner for his or her family, suffers an accident due to outward, violent and visible injuries and passes away within six months from the injury. In such a case, the company is to pay the family a sum of Rs.25,000.

Disability compensation for the breadwinner

A maximum of Rs.750 is to be paid if the breadwinner is ill or hospitalized. The company must pay Rs.50 from the fourth day onwards to a maximum of 15 days.

Universal Health Scheme exclusions

The insured will not be covered in the case of-

Disease, injuries, or death caused due to war or terrorism.
Circumcision, without medical grounds.
Hearing aids or vision aids like spectacles and lenses.
Cosmetic, dental or corrective procedures.
Venereal or congenital diseases.
Self-inflicted injuries.
Suicide/attempted suicide.
HIV/AIDS.
Injuries or death from the influence of alcohol, drugs, or adventure sports.

What is the premium for UHIS (Universal Health Insurance Scheme)?

Universal Health Insurance Scheme premium is different for APL and BPL.

The premium for Above Poverty Line

The premium for individuals is Rs.365 per annum.
For families not more than five people with one spouse and three dependable children, the premium is Rs.548/- per annum.
For families with more than five but less than seven members, including the insured, spouse, first three dependent children and dependent parents, the premium is Rs.730/- per annum.

The premium for Below Poverty Line

For individuals, the premium is Rs. 300, out of which the insured bears Rs.100/- and the government subsidizes Rs.200/-.
For families not more than five people with one spouse and three dependable children, the premium is Rs. 450/- per annum. Out of this sum, Rs.150/- is borne by the individual, and Rs.300/- is a government subsidy.
For families with more than five but less than seven members, including the insured, spouse, first three dependent children and dependent parents, the premium is Rs. 600/- per annum, out of which Rs. 200/- is paid by the individual and the rest is subsidized by the government.

Eligibility criteria

The eligibility is based on the fact if the individual is Above or Below the Poverty Line.

Eligibility for APL

The total income of the family is expected to be over a stipulated amount. Individuals can opt for this scheme coverage for members aged between 5 and 65 years. Children and infants too are covered from the age of 3 months to 5 years as long as the plan covers their parents.

Eligibility for BPL

A family's income must be less than a stipulated amount to make them eligible for this scheme. A certificate issued from an official like a BDO, tehsildar, etc., is also to be submitted. The age bracket is 5 to 70 years. Children from the age of 3 months to 5 years are also a part of this scheme till their parents are also covered.

How to register for Universal Health Insurance Scheme

To enroll yourself for UHIS, visit a concerned insurance provider to help you apply for the scheme.

If you wish to apply for BPL benefits, you will need a certificate issued from an official like a BDO, tehsildar, etc., as proof of your income. Providing the Universal Health Insurance Scheme documents is crucial for easy enrollment.

This is mainly formed for BPL families to avail medical benefits; however, APL families can also avail of this help at nominal costs. The maternity benefits add a perk to this scheme.

Frequently Asked Questions

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What are the conditions for availing the hospital benefits?

There are a few conditions to meet if you want medical compensation-

All claims under the policy are to be paid in INR.
All medical services are to be availed in India.
TPA will pay the insured person or the hospital directly.

Do I get a refund if I cancel the policy during the relief period?

Yes, you can opt to cancel the policy provided there has been no claim made in that period.

Can a maternity claim be made on the second child?

No, a maternity claim can only be made on the first child.