West Bengal Rolls Out Rs 5 Lakh Health Cover Outside Ayushman Bharat

West Bengal has introduced a health scheme for residents who remain outside the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana. The Mukhya Mantri Swasthya Bima Yojana will give eligible families cashless hospitalisation cover of up to Rs 5 lakh a year.

The scheme is aimed mainly at permanent residents covered under Swasthya Sathi who have not qualified for Ayushman Bharat. The cover will be available on a family-floater basis for secondary and tertiary hospital treatment.

Who Can Receive The Cover?

A family must be a permanent resident of West Bengal, remain outside Ayushman Bharat, and meet the income and other conditions notified by the state government. Its annual income cannot exceed Rs 8 lakh.

There is no limit on the number of family members who may be covered. Pre-existing illnesses will be included from the beginning, without a waiting period. Aadhaar-based authentication will be needed during enrolment, admission and discharge, while an ABHA ID will be used during hospitalisation, according to a recent report by Mint.

Eligible families can receive treatment at hospitals empanelled under Ayushman Bharat across India. This portability may help households whose members live, work or seek specialised treatment outside West Bengal.

Who Will Be Left Out?

People already receiving medical protection through another government-backed arrangement will generally not qualify. This includes employees and pensioners covered under the West Bengal Health Scheme, Central Government Health Scheme or Employees’ State Insurance scheme.

Employees and pensioners of public sector undertakings, statutory bodies, urban local bodies and other government-linked organisations may also be excluded if they receive group medical insurance or a regular medical allowance.

People aged 70 years and above are outside the scheme because they are eligible for senior-citizen coverage under Ayushman Bharat. The notification also excludes certain people whose names were removed during the Special Intensive Revision of electoral rolls. Applicants with pending Citizenship Amendment Act applications or cases before an SIR adjudication tribunal may, however, remain eligible if they satisfy the other conditions.

Cashless Treatment, But No Reimbursement

The Rs 5 lakh limit applies to the family as a whole during a policy year. Treatment must be taken through the cashless route at an eligible hospital. A beneficiary who pays the bill directly cannot later seek reimbursement.

Beneficiaries will also not be allowed to use more than one state, central government, public sector or parastatal health scheme for the same coverage period. Treatment packages and medical rules are expected to broadly follow Ayushman Bharat guidelines.

The state notification outlines the benefits and exclusions, but residents should check the official enrolment instructions before submitting documents. Families should ensure their Swasthya Sathi records, Aadhaar details, and income declaration are correct to avoid problems during verification.

FAQs

1. Who is eligible for the Mukhya Mantri Swasthya Bima Yojana?

Permanent West Bengal residents outside Ayushman Bharat may qualify if their annual family income is up to Rs 8 lakh and they meet the notified conditions.

2. How much health cover does the scheme provide?

Eligible families can receive cashless secondary and tertiary hospital treatment of up to Rs 5 lakh a year on a family-floater basis.

3. Are pre-existing illnesses and reimbursement claims covered?

Pre-existing illnesses are covered from the beginning. However, treatment must be cashless at an eligible hospital, as bills paid directly will not be reimbursed.