Can Both OPD & IPD Expenses be Covered under the Swasthya Sathi Scheme?

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Under the Swasthya Sathi Scheme, only the In-Patient Department (IPD) is fully covered, not the Outpatient Department (OPD).


This is because the scheme, launched by the Government of West Bengal on December 30, 2016, generally focuses on providing inpatient benefits to families, with a coverage limit of up to ₹5 lakh. To get the details on how medical coverage in the Swasthya Sathi Scheme works, continue reading.


How are the IPD Expenses Covered Under the Swasthya Sathi Scheme?



  • Coverage Starts After Hospital Admission


IPD coverage applies when the patient is formally admitted to the hospital for treatment, surgery, or emergency care. Therefore, in most cases, the scheme generally does not cover routine outpatient consultations without admission.



  • Cashless Treatment Facility Available


Beneficiaries can avail of cashless treatment at empanelled government and private hospitals from 1 day prior to hospitalisation. However, at the hospital, the Swasthya Sathi desk will verify your smart card to confirm your eligibility.



  • Available for the Entire Family


The IPD benefits of this scheme are provided as a family floater benefit, with no premium. This means that, under this scheme, all family members will be covered by a single policy. In fact, since this scheme has no cap on family size, it will cover in-laws and even any physically challenged dependent family members.



  • Hospital Room Charges Coverage


The scheme generally covers hospital accommodation expenses, including general ward charges and ICU expenses, without any sub-limits. Considering the rising medical inflation in India, which is around 12%-15% annually, as reported by the Economic Times, this benefit will significantly reduce your financial burden during medical emergencies.



  • Medical and Surgical Expenses


IPD coverage under Swasthya Sathi will cover doctor consultation fees during admission. Additionally, policyholders will receive coverage for surgery expenses, medicines, and even diagnostic tests related to treatment during hospitalisation.



  • Coverage for Emergency Hospitalisation


Patients admitted due to accidents, serious illness, or emergency medical conditions can also avail themselves of the scheme's treatment benefits. However, it is subject to hospital empanelment and package approval.



  • Pre-Approved Treatment Packages Apply


The scheme works on fixed treatment packages approved by the government. This means hospitals can provide cashless treatment only for treatments included under these packages. However, since these packages include over 2,000 specific medical and surgical treatments, such as cardiology and orthopaedic care, necessary treatments are easily accessible.


Why is OPD Coverage Usually Limited in the Swasthya Sathi Scheme?


Government health insurance schemes primarily focus on reducing the financial burden of major hospitalisation expenses. Since OPD treatments, such as routine checkups, are frequent and recurring, they are usually not included in these schemes.


However, in this scheme, prescribed medications and diagnostic tests required after discharge are covered for up to 5 days. But remember, it has to be included in your approved treatment package at the empanelled hospitals.


Final Words


The Swasthya Sathi Scheme primarily covers IPD or hospitalisation-related expenses. As a result, routine OPD expenses are not included under the scheme. This is why understanding the coverage details, exclusions, and approved treatment packages will help you make better healthcare and financial decisions.