Summary of this article
NPS Swasthya combines retirement savings with health coverage.
It offers flexible deductible tiers up to a Rs 30 lakh floater cover.
The scheme includes partial withdrawals for medical bills.
The Pension Fund Regulatory and Development Authority (PFRDA) has issued detailed guidelines for National Pension System (NPS) Swasthya, a retirement pension scheme with health insurance coverage. Under these guidelines, anyone eligible to join NPS can also join NPS Swasthya.
The scheme follows a distinct dual structure: an NPS Swasthya Investment account and a separate super top-up health insurance policy. While the insurance component is compulsory for enrolment in the scheme, PFRDA has clarified that both schemes remain operationally and legally distinct.
Anyone between the age of 18 and 70 can enrol under the scheme, and renewal is permitted up to 85 years of age. PFRDA has standardised four annual aggregate deductible tiers tied to family floater sum insured amounts. Here are the details.
The mandatory super top-up policy is offered under a master policy arrangement by pension funds (PFs) through insurers registered with the Insurance Regulatory and Development Authority of India (Irdai).
It provides family floater coverage for the subscriber, spouse, and up to two dependent children, specifically excluding parents. The annual aggregate deductible shall apply to cumulative insurance of all covered family members during the policy year. These are:
Rs 10,000 deductible for Rs 1 lakh family floater sum insured
Rs 50,000 deductible for a Rs 5 lakh family floater sum insured
Rs 1 lakh deductible for a Rs 10 lakh family floater sum insured
Rs 3 lakh deductible for a Rs 30 lakh family floater sum insured
The standard policy covers single private rooms for normal hospitalisation, actual intensive care unit (ICU) charges, 30 days of pre-hospitalisation, 60 days of post-hospitalisation, and road ambulance expenses up to Rs 2,500.
Minimum Contribution And Investment
The minimum initial contribution to enrol in the scheme includes the first-year insurance premium (inclusive of taxes), an annual health benefit administrator (HBA) maintenance charge of Rs 200 and taxes, and at least Rs 1,000 for investment in the NPS Swasthya account.
Once enrolment is complete, subsequent contribution can be as low as Rs 10.
NPS Swasthya fund investments will be in the same pattern as the Central Government Scheme investment pattern. PFs may levy up to 0.08 per cent fee per annum for asset management.
Subscribers can make partial withdrawals of up to 25 per cent of their total contributions for outpatient (OPD) and inpatient (IPD) treatments. There is no minimum waiting period and no restriction on withdrawal. Payment will be settled directly with healthcare providers rather than the subscribers.
In case a single IPD bill goes above the partial withdrawal limit, subscribers can opt for a premature exit and withdraw their entire accumulated corpus towards the medical bill. In such cases, the remaining balance is merged into a standard All Citizen Model NPS account. In the same way, if a subscriber fails to renew their insurance after advance alerts at 90, 60, and 30 days, the cover will lapse, and the account will convert into an All Citizen Model Account.
Service Timelines
PFs must engage the Association of NPS Intermediaries (ANPI) empanelled HBAs. The guidelines mandate strict service level agreements (SLAs), such as:
Cashless pre-authorisation processing within 1 hour.
Final discharge authorisation within 3 hours.
Planned IPD corpus withdrawal to be approved by the HBA within 1 working hour.
Platform uptime must maintain at least 99.5 per cent availability monthly.
PFRDA strictly prohibits PFs from receiving insurance commissions, claim-linked payments, or share in premiums. The health data is also restricted to authorised purposes and is barred for profiling, marketing, and provider steering. Subscribers can lodge complaints across all stakeholders through the Pension Sahayak platform.
