Swasthya Sathi Scheme - Eligibility, Benefits, Card Apply & More

• The Swasthya Sathi scheme provides comprehensive health coverage up to ₹5 lakh per family per year. This flagship initiative is by the West Bengal Government.
• The Swasthya Sathi card simplifies the process of receiving medical care. By presenting this card, beneficiaries can easily access a wide range of medical facilities and services without upfront payments.
• A key feature of the Swasthya Sathi scheme is its digitalisation. Beneficiaries can check their Swasthya Sathi status online and access the Swasthya Sathi card hospital list through the official website and mobile app.

Health insurance is essential for protecting yourself financially and ensuring peace of mind. It covers medical expenses and provides security during health emergencies. In West Bengal, the need for health insurance is particularly significant due to the large population and varying access to medical facilities.To address this need and make health insurance accessible and affordable, the West Bengal Government launched the Swasthya Sathi in December 2016. The objective of this scheme is to provide comprehensive health coverage to all residents of West Bengal.This following write-up will explain the Swasthya Sathi scheme , how to apply for the Swasthya Sathi card , check the Swasthyasathi status online, and more.

The Chief Minister of West Bengal launched the Swasthya Sathi scheme on 30th December 2016. It provides group insurance for citizens of West Bengal and health facilities to families, regardless of their financial condition. The main objective is to help residents get cashless treatments.With the Swasthya Sathi card , families can access necessary medical services without upfront payments. This makes healthcare more accessible and affordable for everyone in West Bengal.

An Overview of Swasthya Sathi Scheme

The following table highlights the Fundamentals of the Swasthya Sathi Scheme -

Scope of Swasthya Sathi Scheme

The Swasthya Sathi covers every district of West Bengal, reaching around 2 crore families. This includes families of self-help groups, ASHA workers, ICDS workers, helpers, civil defense volunteers, civic volunteer forces, and certain categories of contractual employees.Additionally, all beneficiaries of the Rashtriya Swasthya Bima Yojana and other eligible families based on SECC deprivation criteria are included. Currently, over 142 lakh families are eligible for the Swasthyasathi package .From 1st December 2020, the government expanded the coverage to include all residents of the state, irrespective of caste, religion, affiliation, creed, or profession. The scheme has more than 2290 hospitals in its panel, and about 34 lakh people have been hospitalised under the scheme.

The key features of Swasthyasathi package are listed below -

• Comprehensive Health Coverage: The Swasthya Sathi provides health coverage for secondary and tertiary care up to ₹5 lakh per family. Now, families can access necessary treatments without financial stress.
• Coverage for Pre-existing Conditions: All pre-existing medical conditions are covered under the Swasthya Sathi scheme .
• No Family Size Limit: There is no limit on the size of the family covered. Every member of the family is eligible for health coverage under the Swasthya Sathi .
• No Contribution Required: Beneficiaries do not need to contribute financially. The entire premium is borne by the state government to provide free health coverage for all eligible families.
• Smart Card Transactions: The scheme operates using a Swasthya Sathi card. This smart card facilitates cashless transactions and is automatically renewed each year.
• Paperless and Hassle-free Platform: It operates on a paperless, IT-based platform. This makes the process hassle-free and efficient for beneficiaries.
• Quick Pre-authorisation: All medical procedures for Swasthya Sathi are 100% pre-authorised within 24 hours. This offers timely access to necessary treatments.
• Graded Hospitals: Hospitals are graded based on facilities and services. This grading is approved by the Empowerment Committee to provide quality care for beneficiaries.
• Cashless Coverage: The Swasthya Sathi scheme offers cashless coverage for consultations, diagnostics, medicines, food during hospitalisation, and post-discharge medicines for the same ailments. This comprehensive coverage reduces out-of-pocket expenses for families.
• Extensive Package List: The Swasthya Sathi offers around 2092 packages with different rates adjusted by the Package Selection Committee.
• SMS Updates: Beneficiaries receive SMS updates during hospitalisation and after discharge. This keeps them informed about their treatment and coverage.
• Mobile App Support: A mobile app is available to help beneficiaries with queries, information sharing, and a one-touch feature for a 24x7 helpline. It gives easy access to support and information.
• Transport Allowance: A transport allowance of ₹200 is provided at the time of discharge. Additional allowances are available for patients referred to state government-run hospitals.
• Quick Claim Settlement: Claims are generally settled within 30 days. If there is a delay, interest is payable to the beneficiaries.
• E-health Reports: E-health reports are provided at discharge. These reports are accessible to physicians for future consultations.
• Monthly Analytical Reports: A monthly analytical report is disclosed in the public domain for review and suggestions from stakeholders. It aids in transparency and continuous improvement.
• Online Grievance Monitoring: There is an online grievance monitoring mechanism. It uses machine intelligence and human intervention to spot unusual patterns like high admissions and unnecessary surgeries.
• Interactive Website: An interactive Swasthya Sathi website features all important information and details online. This makes it easy for beneficiaries to access relevant information.
• Hospital Coverage : Multiple hospitals provide treatment under S wasthya Sathi scheme. Swasthya Sathi card hospital list is given on the official website.

Also Read : West Bengal Health Scheme: Eligibility, Coverage, and Benefits

The Swasthya Sathi scheme offers a comprehensive range of health coverages for the well-being of beneficiaries.Here are the key inclusions provided by Swasthya Sathi scheme -

• In-patient Hospitalisation: Coverage for expenses related to in-patient hospitalisation, including room charges, doctor fees, nursing charges, and medication costs up to ₹5 lakh per family per year.
• Pre and Post-hospitalisation: Coverage for medical expenses incurred up to 1 day before hospitalisation and up to 5 days after discharge.

• Day Care Treatments: Coverage for specific medical procedures that do not require a full day's hospitalisation. This includes treatments like chemotherapy, dialysis, radiotherapy, and minor surgeries.

• Maternity Benefits: Coverage for childbirth, including normal delivery, caesarean section, and treatment for complications arising from pregnancy.
• Newborn Coverage: Automatic coverage for newborns from birth until the end of the policy year, including all necessary treatments.

• Transport Allowance: Provision of ₹200 for transportation per hospitalisation, with an annual ceiling of ₹2000.
• Diagnostic and Surgical Procedures
• Surgical Procedures: Coverage for a wide range of surgical procedures, so that beneficiaries receive necessary surgical care without financial strain.
• Diagnostic Tests: Coverage for diagnostic tests required for treatment, including X-rays, MRIs, CT scans, and laboratory tests.

• Emergency Ambulance Services: Coverage for emergency ambulance services for timely transportation to the hospital.

• Prosthetics and Implants: Coverage for the cost of prosthetic devices and implants necessary for treatment.
• ICU Charges: Coverage for Intensive Care Unit (ICU) charges.

• Hospitalisation Coverage
• Day Care Procedures
• Maternity and Newborn Care
• Transport Allowance
• Emergency Services
• Additional Benefits

The Swasthya Sathi offers extensive health coverage, but certain conditions and treatments are excluded from the scheme.Here are the primary exclusions -

General Exclusions

• Conditions Not Requiring Hospitalisation: Treatments that do not require hospitalisation and can be managed through outpatient care.
• Evaluation and Diagnostics: Expenses primarily for evaluation, diagnostics, and routine check-ups unless necessary for treatment of a covered illness.
• Non-medical Expenses: Costs such as vitamins and tonics unless part of the treatment for a covered condition.

Specific Exclusions

• Cosmetic and Dental Procedures: Cosmetic treatments, dental procedures, and surgeries for aesthetic purposes, including root canals and dental implants, unless required due to an accident.
• Substance Abuse: Treatments related to illnesses or injuries resulting from drug, alcohol, or substance abuse.
• Fertility Treatments: Any fertility-related treatments, hormone replacement therapy, and procedures related to sex change.
• Vaccinations and Preventive Treatments: Routine vaccinations, inoculations, and preventive treatments unless required as part of the treatment for a covered illness.

Special Cases

• Self-inflicted Injuries: Injuries or illnesses resulting from intentional self-harm or attempted suicide.
• War and Nuclear Events: Health issues caused by war, invasion, or nuclear contamination.
• Experimental Treatments: Any treatments or procedures that are experimental and not widely accepted as standard medical practice.

Maternity Exclusions

• Voluntary Termination of Pregnancy: Expenses related to voluntary medical termination of pregnancy unless induced by an accident or required to save the life of the mother.
• Short Hospitalisation Period: Hospitalisation for childbirth if the stay is less than 48 hours post-delivery.

The Swasthya Sathi card is an essential part of the Swasthya Sathi scheme provided by the West Bengal Government. It ensures that beneficiaries receive cashless and hassle-free healthcare services. The card simplifies the process of getting medical treatment without the need for upfront payments. Beneficiaries can access a wide range of medical services and treatments using this card.Some of the notable features of Swasthya Sathi card are as follows -

• Cashless Treatment: Facilitates cashless medical treatment at empanelled hospitals.
• Smart Card Technology: Operates on a paperless and IT-based platform for ease of use.
• Automatic Renewal: The card is automatically renewed each year for continuous coverage.
• Online Application: Swasthya Sathi card online apply can be done on the official website of Swasthya Sathi .

The Swasthya Sathi provides health coverage to a wide range of residents in West Bengal. The eligibility criteria for obtaining a Swasthya Sathi card include -

• Resident of West Bengal: The scheme is open to all residents of the state.
• Self-Help Groups: Members of self-help groups are eligible.
• ASHA Workers and ICDS Workers: Accredited Social Health Activists (ASHA) and Integrated Child Development Services (ICDS) workers and helpers qualify.
• Contractual Workers: Certain categories of contractual employees are included.
• Rashtriya Swasthya Bima Yojana (RSBY) Beneficiaries: Existing RSBY beneficiaries are covered.
• Low-Income Families: Families meeting specific deprivation criteria based on the Socio-Economic Caste Census (SECC) are eligible.
• Universal Coverage: From 1st December 2020, the scheme was expanded to cover all residents, irrespective of caste, religion, or profession.

Exemptions: While the scheme aims for universal coverage, certain groups may be excluded, such as high-income families and those already covered under other government health insurance schemes.

To apply for the Swasthya Sathi card under the Swasthya Sathi , applicants need to submit a set of essential documents.Here are the required documents for registration -

• Aadhaar Card: This serves as a primary proof of identity.
• Photo ID Card: If Aadhaar is not available, any government-issued photo ID card can be used.
• Domicile Proof: Legal domicile documents to confirm residency in West Bengal.
• Ration Card: For families, the ration card helps verify family members.
• Passport-size Photographs: Recent photographs of the applicant and family members.
• Mobile Number: A registered mobile number for receiving SMS updates and notifications.
• SECC ID: The Socio-Economic Caste Census ID, if applicable.

Also Read: Health Insurance 101: Guide on the Basics of Health Insurance

Swasthya Sathi card online apply under the Swasthya Sathi is a simple process. Here are the steps and methods to apply for the card.

Swasthya Sathi Card Apply Online Process

• Step 1: Visit the official Swasthya Sathi Online Application Portal ( Swasthya Sathi ).
• Step 2: Select your district, block/municipality, and category (OBC, SC, ST, Others).
• Step 3: Fill in the residential address, pincode, applicant's name, and details of the head of the family (HOF).
• Step 4: Provide employment details if applicable and confirm if any family member receives government-sponsored health insurance or medical allowances.
• Step 5: Add the details of all family members, including their Aadhaar number, ration card number, employment status, and mobile number.
• Step 6: Upload necessary documents such as proof of identity, domicile proof, and photographs.
• Step 7: Submit the application form and note the unique registration number (URN) provided.

• Step 1: Collect Form-B from the nearest government hospital, ward office, Grama Panchayat, or village medical centre.
• Step 2: Complete the form with accurate details of the family members and their respective documents.
• Step 3: Submit the filled form along with required documents at the designated submission centres.
• Step 4: You will receive an SMS with your URN, district code, and serial number.
• Step 5: The Swasthya Sathi card will be delivered to you within a week from the date of submission.

• You can also register for the Swasthya Sathi card through authorised agents located at ward offices, Grama Panchayats, or village medical centres. These agents will assist you in filling out the form and submitting it on your behalf.

• Online Application
• Offline Application
• Through Authorised Agents

Checking the Swasthyasathi status online involves a few steps.. Whether you want to verify your application status or ensure your card is active, you can do it conveniently from the comfort of your home.Here’s a detailed guide on how to Swasthya Sathi status check online West Bengal -

Steps to Check Swasthya Sathi Status Online

• Visit the Official Swasthya Sathi Website: Go to the official Swasthya Sathi website.
• Access the Status Check Page: On the homepage, click on the ‘Apply Online’ option and then the ‘Swasthya Sathi - Check Your Registration Status’ tab.
• Select Your District: From the dropdown menu, select your district. The options will include all districts in West Bengal such as Alipurduar, Bankura, Birbhum, and others.
• Choose Your Search Criteria: You can search using different criteria like Family ID, URN (Unique Registration Number), or Aadhaar number. Select the appropriate option based on the details you have.
• Enter Required Information: Input the necessary details as per your selected search criteria. Ensure the information is accurate to avoid any errors.
• Submit the Details: Click on the "Submit" button to proceed. The system will then display your Swasthyasathi status .

Also Read: Medical Insurance: Compare Medical Insurance Plans in India

Alternative Method: Using the Mobile App

• Download the Swasthya Sathi Mobile App: The Swasthya Sath i mobile app is available for Android users. Download it from the Google Play Store.
• Log in to the App: Use your registered mobile number to log in.
• Check Status: Navigate to the status check section within the app to view your application status and other details.

The Swasthya Sathi app is a mobile application designed to facilitate and enhance the accessibility of the Swasthya Sathi scheme launched by the West Bengal Government. This app, available for Android devices, provides a range of features aimed at simplifying healthcare access for beneficiaries.

Key Features of the Swasthya Sathi App

• Real-Time Information: The app offers real-time uploading of e-health records, which can be accessed by physicians for better continuity of care.
• SMS Alerts: Beneficiaries receive SMS alerts during hospitalisation and after discharge, keeping them informed about their Swasthya Sathi status .
• 24x7 Helpline: The app includes a one-touch feature to connect directly to a 24x7 helpline for assistance.
• Grievance Redressal: Users can raise grievances and seek resolutions through the app's online grievance monitoring mechanism.
• Hospital Information: Provides details about empanelled private and public hospitals and helps users to find appropriate healthcare facilities.
• Check Status: The Swasthya Sathi app also allows users to check their Swasthya Sathi status online and facilitates the Swasthya Sathi card online apply process.

Swasthya Sathi Card Hospital List

The Swasthya Sathi scheme includes a comprehensive list of hospitals that are graded based on the services they offer. The grades are as follows -

• Grade A: Hospitals with top-tier facilities and extensive services.
• Grade B: Hospitals offering a wide range of medical services.
• Grade C: Hospitals providing basic medical services.
• Grade R: Reserved for specialised hospitals focusing on critical care.
• Critical Illness Package: Hospitals specialised in treating critical illnesses.
• Implants (Orthopedics and Cardio): Facilities focusing on orthopaedic and cardiac implants.
• Investigation Package (NABH and Non-NABH): Hospitals offering comprehensive diagnostic services, categorised based on NABH accreditation.

To view the Swasthya Sathi card hospital list , follow these steps -

• Visit the Official Website: Go to the Swasthya Sathi website.
• Navigate to Active Hospital List: Under the "Hospital" section, click on "Active Hospital List."
• Fill in the Form: Select your state, district, subdivision, hospital type, and hospital grade.
• Download the List: After filling in the required details, submit the form to view and download the Swasthya Sathi card hospital list of empanelled hospitals.

Process for Swasthya Sathi Hospital Registration

Hospitals looking to register under the Swasthyasathi package can follow a structured process managed by the Swasthya Sathi Samiti, which oversees the scheme.Here’s a detailed guide on how you can add your medical facility in Swasthya Sathi hospital list -

• Enter the CE License number and its status.
• Select the state (West Bengal) and the district where the hospital is located.
• Specify if the hospital is NABH accredited.
• Choose the hospital type (private or public).

• Fill in the hospital name, category, sanctioned bed strength, ownership status, and other administrative details such as the owner or administrator's name and contact information.

• Upload PDF copies of the NABH certificate and other required documents. Make sure that the filenames do not contain spaces.

• Certify that all provided information is accurate to the best of your knowledge. Acknowledge that any incorrect information can result in the hospital being delisted from the scheme.

• After reviewing all entered information, submit the form. An OTP will be sent to your registered mobile number or email for verification.

• The submitted application will be reviewed by the Swasthya Sathi Samiti. Once approved, the hospital will be listed under the Swasthya Sathi .

• To check the status of your hospital registration, visit the Swasthya Sathi Hospital Registration Status page on the official website of Swasthya Sathi .

• Visit the Official Registration Portal Go to the Swasthya Sathi Hospital Registration page ( Swasthya Sathi ).
• Fill in the Required Details:
• Provide Hospital Information:
• Upload Necessary Documents:
• Agree to Terms:
• Submit the Form:
• Verification and Approval:
• Check Registration Status:

Cashless Claim under Swasthya Sathi

The Swasthya Sathi scheme offers a cashless claim procedure. Here is a detailed guide on how to proceed with cashless claims under the Swasthyasathi package . Steps for Cashless Claims

• Online Registration: When a patient arrives at an empanelled hospital, their details are registered online through the hospital's system.
• Identity Verification: The patient's identity is verified using their Swasthya Sathi card . Fingerprints of the patient or any enrolled family member (in case of emergency) are checked to authenticate identity.
• Balance Check: The system checks if the beneficiary has sufficient balance in their Swasthya Sathi card account to cover the treatment costs.
• Pre-Authorisation Request: The hospital sends an online request for prior approval to the insurance company. This request includes all necessary details about the patient's condition and the required treatment.
• Approval Process: The insurance company reviews the request and responds within 12 hours. The decision includes whether the requested procedure is covered under the Swasthya Sathi package .
• Provisional Entry: Once approval is received, a provisional entry is made on the Swasthya Sathi card , blocking the claim amount for the procedure.
• Treatment and Discharge: After treatment, the hospital makes a final entry on the Swasthya Sathi card , verifying the beneficiary's fingerprint again (or a family member's in case of death).
• Electronic Payment: All payments are processed electronically. The hospital receives the payment within one month of submitting the electronic claim documents in the prescribed format.

Pre-Authorization for Non-Package Procedures For treatments not listed under specific Swasthyasathi package , the following steps are followed -

• Request for Authorization Letter (RAL): The empanelled healthcare provider submits a RAL with detailed medical information to the insurance company's authorisation department.
• Submission Timeline: For emergencies, the RAL must be submitted within 6 hours of admission. For planned admissions, it should be submitted 7 days prior.
• Approval and Negotiation: The insurance company negotiates the package with the healthcare provider and issues an Authorisation Letter (AL) within 12 hours.
• Manual Entry: Details are manually entered into the system if not available in the package list, including the authorisation number and the agreed package amount.
• Payment and Settlement: Payments are made electronically to the hospital, and any discrepancies or additional charges are settled according to the insurance company's policies.

Health insurance is essential for providing financial security and access to healthcare. The Swasthya Sathi is a flagship initiative by the West Bengal Government. It provides comprehensive health coverage to all residents, highlighting the state's commitment to improving healthcare accessibility. This scheme significantly enhances public health and offers much-needed financial protection to families across the state.