On 18 September 2026 the Pension Fund Regulatory and Development Authority issued Circular No. PFRDA/2026/49/NPS-SWASTHYA/01, and with it 27 pages of Operational Guidelines for a scheme called NPS Swasthya. The circular says it comes into force with immediate effect. The scheme had existed only inside PFRDA's regulatory sandbox until now; those sandbox schemes are discontinued the moment these Guidelines are implemented.
NPS Swasthya is not a pension product with a health rider bolted on. It is two separate things that are legally required to travel together: an NPS account whose money can be spent on hospital bills while you are still alive, and a mandatory super top-up health insurance policy sitting on top of it. You cannot enrol in one without the other.
Everything below is read out of the Guidelines themselves. Our copies of all three official documents are linked at the end of this article.
The single idea that makes NPS Swasthya different
A super top-up policy only starts paying after you have spent a fixed amount in a year — the Annual Aggregate Deductible. That deductible is what normally makes super top-up cover cheap and also what makes people avoid it: you still have to find the first Rs 50,000 or Rs 1 lakh yourself.
NPS Swasthya's answer is to make your own NPS money the thing that pays the deductible. Clause 9.1 is explicit about it — you may transfer funds in from an existing NPS account under the All Citizen Model, and the amount you transfer is limited to meeting the applicable deductible under the Insurance Policy. The corpus covers the bottom layer, the insurer covers everything above it.
That also explains the four variants. The deductible and the family floater sum insured are paired, and in every pairing the cover is exactly ten times the deductible.
| Variant | Annual Aggregate Deductible | Family Floater Sum Insured | Insurer's share above the deductible |
|---|---|---|---|
| Entry variant | Rs 10,000 | Rs 1 lakh | Rs 90,000 |
| Mid variant | Rs 50,000 | Rs 5 lakh | Rs 4.5 lakh |
| High variant | Rs 1 lakh | Rs 10 lakh | Rs 9 lakh |
| Top variant | Rs 3 lakh | Rs 30 lakh | Rs 27 lakh |
Two details in clause 30.1 are worth reading twice. The deductible applies to the cumulative admissible expenses of every covered family member across the policy year — it is not re-applied to each claim, which is how most people assume a deductible works. And the family floater covers the subscriber, the spouse and up to two dependent children. Parents are excluded.
What it costs to open an account
Clause 5.1 sets a minimum initial contribution with three components, all payable up front:
- the first-year insurance premium, inclusive of applicable taxes;
- Rs 200 plus taxes as the annual maintenance charge payable to the Health Benefit Administrator; and
- Rs 1,000 towards investment in the NPS Swasthya account itself.
After that the minimum subsequent contribution is Rs 10. On charges, clause 7.1 keeps the ordinary All Citizen Model charges and adds two more on top: up to 0.08% a year of assets under management for managing the NPS Swasthya scheme, and the same Rs 200 annual maintenance charge. Clause 7.3 then shuts the door — no charge other than one permitted or approved by the Authority may be recovered from a subscriber.
The money is invested in the pattern prescribed for the Central Government Scheme, not in a choice of equity and debt funds. That is a conservative, largely debt-weighted mandate, which makes sense for money that may have to be withdrawn at a day's notice to pay a hospital.
We have not published a premium figure anywhere in this article, because the Guidelines do not contain one. Clause 31.1 leaves premium to the insurer under the IRDAI framework and only requires it to be quoted for three entry-age cohorts — 18 to 40, above 40 to 60, and above 60 to 70 — so that schemes can be compared. Any rupee figure you see quoted for NPS Swasthya premium today is not coming from this document.
Withdrawing for a hospital bill: the rules are unusually generous, with one catch
Under ordinary NPS, a partial withdrawal is hedged with conditions. Under NPS Swasthya, clause 8 strips most of them away:
- You may withdraw up to 25 per cent of the contributions you have made to the NPS Swasthya account, for eligible healthcare expenses — out-patient as well as in-patient.
- There is no limit on the number of partial withdrawals.
- There is no minimum waiting period before the first or any later withdrawal.
The catch is clause 8.4, and it is the most important sentence in the whole document for an ordinary subscriber: the withdrawal amount is never paid to you. It is settled directly with the hospital, the healthcare provider or another eligible entity. NPS Swasthya is not a way to take money out of NPS early. It is a way to make NPS money pay a bill on your behalf.
There is also a quiet piece of subscriber protection in clause 30.2(vii). If the insurer declines a claim because of material non-disclosure, that refusal does not by itself block payment of a genuine eligible healthcare expense from your own corpus. Only a fabricated or fraudulent request is barred.
The cover itself
Clause 30 prescribes a standard policy, and clause 29.8 forbids a Pension Fund from onboarding an insurer-specific version that differs from it. The headline terms:
- Entry age 18 to 70 years; renewal may continue up to and including age 85.
- Room entitlement: a single private room for normal hospitalisation; ICU at actuals.
- Pre-hospitalisation 30 days, post-hospitalisation 60 days; road ambulance up to Rs 2,500 per emergency hospitalisation.
- Day-care procedures, in-patient hospitalisation, domiciliary hospitalisation, AYUSH treatment, prescribed modern treatments and organ-donor medical expenses are covered.
- No co-payment and no disease-specific sub-limit.
- Anything the insurance does not pay may still be considered from the NPS Swasthya corpus.
- Cover must start no later than T+1 working days from successful enrolment and receipt of the minimum initial contribution.
- Fresh underwriting at renewal is not allowed except where the sum insured is increased, and a renewal premium increase cannot be imposed merely because you made a claim.
Waiting periods — and a conflict inside the document
Clause 30.2 sets an initial waiting period of 30 days apart from accidents, a pre-existing disease waiting period of 12 months, and a specified disease or procedure waiting period of 12 months.
Clause 30.2(iv) then says that controlled Type 2 diabetes, hypertension, hyperlipidaemia and asthma which do not trigger enhanced underwriting "shall be covered after the initial waiting period of 12 months". The Guidelines have just defined the initial waiting period as 30 days, so these two sub-clauses cannot both be read literally. We are reporting the conflict rather than picking the reading we prefer; the final policy wording filed with IRDAI will settle which number governs those four conditions.
The Good Health Declaration — fifteen questions, and no medical test
Clause 30.3 says enrolment is "ordinarily" on the basis of a Good Health Declaration. You answer for yourself, your spouse and your dependent children, on whether any of you is suffering from, has been diagnosed with, has been advised or has taken treatment for, or has undergone or been advised surgery for, any of the following:
| S. No. | Condition declared in the Good Health Declaration |
|---|---|
| 1 | Heart attack |
| 2 | Stroke, paralysis in any form, or any other cerebrovascular disease |
| 3 | Thyroid or parathyroid disease; chronic or acute kidney disease |
| 4 | Acute or chronic liver failure or disease, cirrhosis of liver, alcoholic liver disease, or pancreatic disease |
| 5 | Lung disease |
| 6 | Blood disorders or gastrointestinal disease such as peptic ulcer |
| 7 | Disorder of the bones, spine or muscle |
| 8 | Cancer or cancerous growth, benign or malignant tumour |
| 9 | Autoimmune disease or disease related to the central nervous system or brain |
| 10 | HIV/AIDS or AIDS-related complications |
| 11 | History of sudden loss of weight in the last one year |
| 12 | Head injury |
| 13 | Major burns |
| 14 | Type 1 diabetes and/or treatment with insulin |
| 15 | Asthma with more than two hospitalisations in the last one year, acute severe bronchial asthma or status asthmaticus |
What happens if you tick one is the interesting part. Clause 30.3(iii) says the insurer applies a premium loading based on the declaration, without requiring formal medical reports. If the proposal is declined outright, you must be told the specific reason — and a decline for one family member does not, by itself, disqualify the others.
Service standards you can hold them to
Most scheme documents promise good service in the abstract. This one puts numbers in a table and says a Pension Fund may make them stricter but may never dilute them.
| Service | Minimum standard | Owed by | Clause |
|---|---|---|---|
| Cashless pre-authorisation | Within one hour of a complete request, or any stricter IRDAI timeline | Insurer / TPA | 30.4 |
| Final discharge authorisation | Within three hours of a complete hospital request | Insurer / TPA | 30.4 |
| Reimbursement | Within 15 calendar days of the last necessary document | Insurer / TPA | 30.4 |
| Corpus authorisation for planned in-patient treatment | Within 1 working hour of complete documentation | HBA | 24.2 |
| Settlement intimation from the corpus | Within 7 working days of the final billing documents | HBA | 24.2 |
| Referral to the insurer, and status updates | Within 5 minutes each | HBA | 24.2 |
| Grievance about HBA service | At least 90% inside 7 working days, 100% inside 15 working days | HBA | 24.2 |
| Platform uptime | At least 99.5% every calendar month | HBA | 24.2 |
Clause 36.6 adds a rule worth knowing before you ever need it: every adverse decision under NPS Swasthya must be conveyed to you with the reason in plain language and must state the escalation route. Under clause 30.4 an adverse insurance decision has to carry the specific policy clause, a standard reason code and the amount calculation.
Grievances go through the Pension Sahayak platform, which clause 37.1 says will let a subscriber complain against any stakeholder — Pension Fund, CRA, Point of Presence, HBA or insurer. Claim-settlement grievances remain the insurer's responsibility under IRDAI regulations.
How the account ends
Clause 11.1 lists four ways an NPS Swasthya account closes, and clause 11.2 confirms that closing it does not touch any other NPS account you hold.
- Premature exit — permitted only where eligible in-patient expenditure in a single instance exceeds what the partial withdrawal route allows. The corpus is first applied to that expenditure; whatever is left is merged into an All Citizen Model NPS account. Any policy already in force runs out its remaining period.
- Premium not funded — if the balance will not cover the renewal premium, the Pension Fund must, where practicable, alert you at 90, 60 and 30 days before renewal. If the premium is still unpaid after the grace period and cover lapses, NPS Swasthya is treated as closed and the money merges into All Citizen Model NPS.
- Normal exit and exit on death — governed by the ordinary non-Government exit provisions of the 2015 Exits and Withdrawals Regulations. Nomination follows the same regulations.
- Switching — you may move from one NPS Swasthya scheme to another only at insurance renewal, which may also change the Pension Fund and the insurer. Waiting periods, portability, moratorium and continuity credits carry forward, and the outgoing insurer stays responsible for claims arising in its own policy period.
Existing sandbox subscribers are not stranded. Clause 16 gives them an option to migrate into a scheme under these Guidelines, or to merge their holding into an All Citizen Model NPS account instead.
Who is actually on the hook
NPS Swasthya introduces a new creature into the NPS architecture: the Health Benefit Administrator, empanelled by the Association of NPS Intermediaries and engaged by a Pension Fund. An HBA runs the digital front end of the healthcare journey, verifies withdrawal eligibility, and talks to the hospital — but clause 3.3 is emphatic that an HBA is not an insurer, a TPA or an insurance intermediary.
The bar to become one is not low: a body corporate in continuous operation for at least two years, net worth of at least Rs 5 crore, average annual turnover of at least Rs 5 crore over three years, two years of relevant healthcare experience, a valid ISO/IEC 27001 certification, at least 5,000 completed in-patient or out-patient transactions already behind it, capacity for 5,000 transactions a month, and annual penetration testing by a CERT-In empanelled auditor.
Two conflict-of-interest rules protect the subscriber directly. Under clause 18.3 the insurer cannot be a promoter-group, holding, subsidiary, associate or common-control entity of the Pension Fund. Under clause 18.8 the Pension Fund may not receive any insurance commission, premium share or claim-linked payment. And clause 17.3 makes the point that matters when something goes wrong: engaging an HBA or an insurer does not absolve the Pension Fund of anything.
The legal trail behind the scheme
NPS Swasthya did not appear out of nowhere in September. It rests on two Gazette notifications, both of which we have mirrored:
- 12 December 2025 (published 15 December 2025, Gazette No. 808, CG-DL-E-16122025-268548) — the Exits and Withdrawals (Amendment) Regulations, 2025 inserted Regulation 4A, creating the category of a "specific purpose scheme" under NPS whose exits and withdrawals are governed by guidelines rather than by the general regulations.
- 13 July 2026 (published 14 July 2026, Gazette No. 450, CG-DL-E-20072026-274607) — the 2026 amendment, under the same file number PFRDA/16/14/06/0009/2018-REG-EXIT, renumbered the existing Regulation 4A as sub-regulation (1) and inserted sub-regulations (2) to (4). These are what allow a Pension Fund to engage another entity to operationalise such a scheme, require that entity to be technically capable of integrating with the CRA, and state that the Pension Fund shall be liable for any act of omission or commission of the entity it engages.
The Guidelines of 18 September 2026 are issued under that Regulation 4A, read with Section 14 of the PFRDA Act, 2013.
What is still not public
Being straight about the gaps: the circular repeatedly refers to a Standard Operating Procedure for the fund-flow process, and that SOP is not a published document. The ANPI panel of Health Benefit Administrators is not out yet, so no HBA can lawfully be engaged until it is. No Pension Fund has published its insurer, its premium table or an enrolment date. Until those land, nobody can tell you what NPS Swasthya will cost them.
What is settled is the shape of the product, and that is unusual enough to be worth knowing early: a retirement account that pays your deductible, an insurance policy that cannot be sold to you in a non-standard version, no co-payment, no disease sub-limits, no medical tests at entry, and a hospital that gets paid by your pension fund.
If you are tracking the government's other recent moves on old-age income, see our breakdown of the Pradhan Mantri Samajik Sahayata Yojana, the renamed NSAP that carries the old-age, widow and disability pensions.