PFRDA NPS Swasthya 2026: Operational Guidelines for NPS and Health Benefits

Summary: The Pension Fund Regulatory and Development Authority (PFRDA) has issued Circular No. PFRDA/2026/49/NPS-SWASTHYA/01 dated September 18, 2026, introducing the “Operational Guidelines for NPS Swasthya under the National Pension System (NPS), 2026”. The Guidelines are issued under Section 14 of the Pension Fund Regulatory and Development Authority Act, 2013 read with Regulation 4A of the Pension Fund Regulatory and Development Authority (Exits and Withdrawals under the National Pension System) Regulations, 2015, and take effect immediately. NPS Swasthya comprises an NPS Swasthya investment account and a separate mandatory super top-up health insurance policy. The framework provides for healthcare-related partial withdrawals up to 25% of subscriber contributions, without a restriction on the number of withdrawals or a minimum waiting period, subject to the prescribed conditions. It also establishes governance and operational responsibilities for Pension Funds, Health Benefit Administrators (HBAs), insurers, Central Recordkeeping Agencies, Trustee Banks and Points of Presence. The Guidelines prescribe eligibility and empanelment requirements for HBAs, service-level standards, cybersecurity and data-governance requirements, subscriber disclosures, grievance-redressal mechanisms and regulatory reporting obligations. The standard insurance framework specifies family coverage, entry-age cohorts, deductible and sum-insured options, waiting periods, continuity provisions and minimum claims and service controls. The Guidelines also provide mechanisms for premature exit, normal exit, death, transfer from existing NPS schemes, renewal-related closure and migration of existing NPS Swasthya subscribers under the Regulatory Sandbox.

International Financial Services Centres Authority

Circular No. PFRDA/2026/49/NPS-SWASTHYA/01 | Dated: September 18, 2026

To,
i. Registered intermediaries of PFRDA
ii. Health Benefit Administrators (‘HBAs’)
iii. Association of NPS Intermediaries (‘ANPI’)
iv. All other NPS Stakeholders

Madam / Sir,

Subject: Operational Guidelines for NPS Swasthya under the National Pension System (NPS), 2026

1. In exercise of the powers conferred under Section 14 of the Pension Fund Regulatory and Development Authority Act, 2013 read with Regulation 4A of the Pension Fund Regulatory and Development Authority (Exits and Withdrawals under the National Pension System) Regulations, 2015 and all other enabling provisions, the Pension Fund Regulatory and Development Authority (hereinafter referred to as ‘Authority’) hereby issues the “Operational Guidelines for NPS Swasthya under the National Pension System (NPS), 2026”, attached with this Circular.

2. These Guidelines shall apply to all registered intermediaries of PFRDA, HBAs and ANPI. Every PF shall ensure that HBA and insurer engaged by it for implementation of NPS Swasthya complies with the applicable provisions of these Guidelines.

3. All concerned intermediaries shall take necessary steps to ensure compliance with the provisions of the Guidelines attached to this Circular and shall establish appropriate systems, processes and controls for effective implementation of NPS Swasthya.

4. The Authority may issue clarifications, operational instructions or directions, from time to time, for the effective implementation of these Guidelines.

5. This Circular shall come into force with immediate effect.

6. The circular is made available on the PFRDA website ([www.pfrda.org.in](http://www.pfrda.org.in)) in the Circular section under the regulatory framework.

Yours faithfully,

Sumit Kumar
Chief General Manager

“NPS Swasthya seeks to enable subscribers to build a dedicated corpus for meeting retirement expenses while facilitating access to health insurance and healthcare-related services through the ecosystem established under NPS architecture. The Scheme provides greater flexibility for healthcare-related withdrawals and specified exit options to enable subscribers to meet eligible healthcare expenses in an efficient and timely manner.”

CHAPTER I – PRELIMINARY

1. Short title and commencement

1.1. These Guidelines may be called the “Operational Guidelines for NPS Swasthya under the National Pension System (NPS), 2026”.

1.2. These Guidelines are issued under Regulation 4A of the Pension Fund Regulatory and Development Authority (Exits and Withdrawals under the National Pension System) Regulations, 2015, and shall come into force from the date specified by the Authority through a circular.

2. Applicability

2.1. These Guidelines shall apply to registered intermediaries of PFRDA participating in NPS Swasthya and shall also apply to the Association of NPS Intermediaries (ANPI) and Health Benefit Administrators (HBAs).

2.2. An insurer and its Third Party Administrator (TPA) shall participate in NPS Swasthya for the purpose of super top-up insurance policy in accordance with the applicable insurance law. Their registration, insurance conduct, product terms, premium, underwriting, policy issuance, claims and insurance related grievances shall remain governed by Insurance Regulatory and Development Authority of India (IRDAI).

2.3. Nothing contained in these Guidelines shall be construed as authorising any entity to undertake insurance solicitation, distribution, underwriting, policy issuance, claim adjudication, TPA activity or any other insurance activity without the registration, permission or appointment required under applicable insurance law.

3. Definitions

Unless the context otherwise requires:

3.1. “Act” means the Pension Fund Regulatory and Development Authority Act, 2013.

3.2. “Eligible Healthcare Expense” means a healthcare expense permitted to be met from the NPS Swasthya corpus under these Guidelines, irrespective of whether the expense is admissible under the Insurance Policy.

3.3. “Health Benefit Administrator” or “HBA” means an entity empanelled by ANPI and engaged by a PF to perform pension-side technology, account-administration, authorization-coordination, recordkeeping, subscriber-interface functions, healthcare technology platform services under NPS Swasthya in accordance with these Guidelines. An HBA is not, by reason of such empanelment, an insurer, TPA or insurance intermediary.

3.4. “Insurer” means an entity registered with the IRDAI and engaged by a PF for NPS Swasthya.

3.5. “Insurance Policy” means a super top-up health insurance policy provided by an insurer engaged by PF under master policy arrangement in respect of NPS Swasthya.

3.6. “NPS Swasthya” means the pension scheme for a specific purpose introduced under Regulation 4A of the Pension Fund Regulatory and Development Authority (Exits and Withdrawals under the National Pension System) Regulations, 2015, to facilitate retirement savings together with such healthcare benefits and insurance policy as may be specified under these Guidelines. PFRDA (Exits and Withdrawals under the National Pension System) Regulations, 2015

3.7. “NPS Swasthya Corpus” means the net asset value of units outstanding in the NPS Swasthya account of a subscriber.

3.8. “Super Top-up insurance” means a supplementary insurance plan that covers total yearly medical expenses once a deductible threshold is crossed. It considers the total medical costs incurred in a policy year, not just individual claims.

3.9. “Third Party Administrator” or “TPA” means an entity appointed by the insurer in accordance with applicable insurance law.

3.10. Words and expressions used but not defined in these Guidelines shall have the meanings assigned to them under the Act, the regulations framed thereunder and the circulars, guidelines or directions issued by the Authority. Insurance expressions shall, where relevant, have the meanings assigned under applicable insurance law and the Insurance Policy.

CHAPTER II – NPS SWASTHYA FRAMEWORK

4. Eligibility and Account Structure

4.1. Any individual eligible to join NPS may enroll under NPS Swasthya, subject to these Guidelines.

4.2. NPS Swasthya shall comprise of,-

(i). an account with an NPS Swasthya investment scheme; and

(ii). a separate super top-up health insurance policy.

4.3. The Insurance Policy shall be mandatory for enrolment under NPS Swasthya. The NPS Swasthya Account and the Insurance Policy shall remain legally and operationally distinct.

4.4. The standard super top-up health insurance under NPS Swasthya, to be provided by an insurer engaged by the PF under master policy arrangement, shall be subject to applicable insurance laws.

5. Contributions

5.1. The minimum initial contribution shall be at least,-

(i). the applicable first-year Insurance Policy premium, inclusive of applicable taxes;

(ii). annual maintenance charges of ₹200, plus applicable taxes, payable to HBA through PFs for undertaking servicing of NPS Swasthya scheme; and

(iii). ₹1,000 towards investment in the NPS Swasthya account.

5.2. The minimum subsequent contribution to NPS Swasthya shall be ₹10.

5.3. The premium shall be remitted to the insurer in accordance with the prescribed fund-flow process given in the Standard Operating Procedure (SoP).

6. Investment

6.1. Contributions received under NPS Swasthya shall be invested in accordance with the investment pattern prescribed for the Central Government Scheme under the applicable PFRDA investment guidelines.

6.2. Each PF shall maintain a separate scheme account for NPS Swasthya.

6.3. The Authority may modify the applicable investment pattern from time to time.

7. Fees and Charges

7.1. The charges applicable to NPS under the All Citizen Model, as specified by the Authority, shall apply to NPS Swasthya. In addition, the PF may levy,-

(i). a charge upto 0.08% per annum of the AUM of the NPS Swasthya corpus, plus applicable taxes for managing the NPS Swasthya; and

(ii). annual maintenance charges of ₹200, plus applicable taxes, payable to HBA through PFs for undertaking servicing of NPS Swasthya scheme.

7.2. All charges shall be disclosed to the subscriber before enrolment and upon any change therein.

7.3. No charge other than a charge permitted or approved by the Authority shall be recovered from the subscriber.

8. Partial Withdrawals

8.1. A subscriber may make a partial withdrawal towards Eligible Healthcare Expenses, including eligible out-patient and in-patient expenses, in accordance with these Guidelines.

8.2. The amount of partial withdrawals shall not exceed twenty-five per cent of the contributions made by the subscriber to the NPS Swasthya account.

8.3. There shall be no restriction on the number of partial withdrawals. No minimum waiting period shall apply to the first or any subsequent partial withdrawal.

8.4. The partial withdrawal amount shall not be paid to the subscriber. The amount shall be settled with the concerned hospital, healthcare provider or other eligible entity towards the Eligible Healthcare Expenses, in accordance with the prescribed fund-flow process given in the SoP.

9. Transfer from an existing NPS Scheme under All Citizen Model

9.1. A subscriber may transfer funds from an existing NPS scheme under the All Citizen Model to the NPS Swasthya account, subject to the amount being limited to meet the applicable deductible under the Insurance Policy.

10. Change of NPS Swasthya scheme

10.1. A subscriber may change from one NPS Swasthya scheme to another at the time of renewal of the insurance policy, in the manner specified by the Authority. Such change may involve a change of PF and the associated insurance policy.

10.2. The PF shall ensure that the outgoing and incoming insurers comply with applicable requirements relating to migration, portability, waiting periods, moratorium and continuity credits, in accordance with applicable insurance laws and directions issued by IRDAI.

10.3. The PF shall ensure that the outgoing insurer remains responsible for claims arising during its policy period, in accordance with the insurance policy and applicable law. A switch shall not affect any admitted, pending or reopened insurance claim or grievance.

11. Closure of NPS Swasthya Account

11.1. An NPS Swasthya account shall be closed upon: (i). normal exit; (ii). premature exit; (iii). non-availability of funds to renew insurance; or (iv) death of the subscriber.

11.2. Closure of the NPS Swasthya account shall not affect any other NPS account maintained by the subscriber.

12. Premature Exit

12.1. A subscriber may opt for premature exit from the NPS Swasthya account where eligible inpatient healthcare expenditure in a single instance exceeds the amount permissible through partial withdrawal.

12.2. On premature exit, the accumulated NPS Swasthya corpus shall first be utilised towards the eligible in-patient healthcare expenditure. In case of any remaining balance, NPS Swasthya scheme shall be closed and merged to an NPS scheme under the All Citizen Model. Where the subscriber does not have an existing NPS scheme under the All Citizen Model, the NPS Swasthya scheme shall be changed into an NPS scheme under the All Citizen Model.

12.3. Upon such change, the NPS Swasthya account shall stand closed. Any Insurance Policy already in force shall continue for its remaining policy period, in accordance with its terms and applicable insurance law.

13. Normal Exit and Exit due to Death

13.1. The exit provisions applicable to non-Government subscribers under the Pension Fund Regulatory and Development Authority (Exits and Withdrawals under the National Pension System) Regulations, 2015, shall apply to NPS Swasthya. PFRDA (Exits and Withdrawals under the National Pension System) Regulations, 2015

14. Non-availability of funds to renew insurance

14.1. Where the available balance may be insufficient for renewal premium, the PF shall, where practicable, alert the subscriber at least 90, 60 and 30 days before renewal. The applicable grace period and consequences of non-payment shall be disclosed clearly. If premium remains unpaid after the applicable grace period and cover lapses, the NPS Swasthya shall be treated as closed.

14.2. In such cases, NPS Swasthya scheme shall be closed and merged to an NPS scheme under the All Citizen Model. Where the subscriber does not have an existing NPS scheme under the All Citizen Model, the NPS Swasthya scheme shall be changed into an NPS scheme under the All Citizen Model.

15. Nomination

15.1. The nomination provisions applicable to non-Government subscribers under the Pension Fund Regulatory and Development Authority (Exits and Withdrawals under the National Pension System) Regulations, 2015, shall apply to NPS Swasthya. PFRDA (Exits and Withdrawals under the National Pension System) Regulations, 2015

16. Existing NPS Swasthya Subscribers under Regulatory Sandbox

16.1. The NPS Swasthya schemes offered under the Regulatory Sandbox shall be discontinued upon implementation of these Guidelines.

16.2. Existing subscribers under the NPS Swasthya scheme offered under the Regulatory Sandbox shall be provided an option to migrate to an NPS Swasthya scheme offered under these Guidelines, in the manner specified by the Authority.

16.3. Such subscribers may also opt to merge their NPS Swasthya Scheme to an NPS scheme under the All Citizen Model, in accordance with the prescribed process. Where the subscriber does not have an existing NPS scheme under the All Citizen Model, the NPS Swasthya scheme shall be changed into an NPS scheme under the All Citizen Model.

16.4. The PF, CRA and other intermediaries concerned shall facilitate such migration or transfer and ensure continuity of the subscriber’s records, benefits and applicable insurance coverage, in accordance with the prescribed process.

CHAPTER III – PENSION FUND (PF)

17. Governance of NPS Swasthya

17.1. NPS Swasthya shall be offered and managed by PFs registered with the Authority, in accordance with the Act, regulations, these Guidelines and the conditions of approval.

17.2. Every PF offering NPS Swasthya shall maintain an adequate governance, operational, technology, risk and control framework covering NPS Swasthya administration, HBA engagement, the insurance policy, data governance, conflicts of interest, grievance handling, business continuity and orderly migration or exit.

17.3. Engagement of an HBA, insurer or any service provider shall not absolve the PF of its responsibilities under the Act, the regulations, these Guidelines or the directions issued by the Authority.

17.4. The PF shall remain solely responsible for ensuring compliance with all regulatory requirements relating to NPS Swasthya, irrespective of whether any activity is performed directly or through an HBA.

18. Responsibilities of PF

18.1. Design, implement and administer NPS Swasthya in accordance with these Guidelines and the approval granted by the Authority.

18.2. Select and engage an empanelled HBA through a transparent process, execute the agreement and monitor the performance of the HBA.

18.3. Select an eligible participating insurer through a transparent process and maintain the insurance policy required for NPS Swasthya. The insurer shall not be a promoter-group, holding, subsidiary, associate or common-control entity of the PF.

18.4. Act as the master policyholder only where permitted under applicable insurance law and the Insurance Policy.

18.5. Monitor the performance of the HBA(s) and insurer engaged under NPS Swasthya and take appropriate corrective action, wherever necessary.

18.6. Establish systems for subscriber servicing, grievance redressal, incident management, data quality, business continuity and regulatory reporting.

18.7. Maintain adequate records relating to the administration of NPS Swasthya and furnish such information to the Authority, in such form and manner, as may be specified.

18.8. Not receive any insurance commission, premium share, claim-linked payment or other insurance consideration that may create a conflict with the interests of subscribers.

18.9. Ensure compliance with the Act, regulations, these Guidelines and directions issued by the Authority from time to time.

19. Engagement of HBA

19.1. A PF may engage one or more HBAs from the panel maintained by ANPI.

19.2. The engagement of an HBA shall be governed by a written agreement specifying the scope of services, service levels, fees, confidentiality, data roles, information security, business continuity, reporting, audit rights, conflicts of interest, liability, dispute resolution, termination and transition arrangements.

19.3. The HBA fee shall be as given in clause 7.1.

19.4. Where more than one HBA is engaged, the PF shall clearly allocate responsibilities and ensure seamless subscriber servicing and portability of records.

20. Supervision and Oversight of HBA

20.1. The PF shall establish an effective oversight mechanism to monitor the performance, compliance and service standards of each HBA engaged by it.

20.2. The PF shall ensure that each HBA provides timely access to information, records and documents required for compliance with the Act, regulations, these Guidelines and directions issued by the Authority.

20.3. The PF shall conduct periodic reviews of the service level agreements and controls and undertake due diligence of each HBA at least annually. Any deficiencies identified shall be addressed through a time-bound corrective action plan.

20.4. Any material breach, harm to subscribers, data incident or loss of eligibility of an HBA shall be reported promptly to ANPI and the Authority.

20.5. The Authority may call for such information, records or documents relating to NPS Swasthya from the PF as it may deem necessary. The PF shall obtain and furnish such information, records or documents from the HBA or insurer, as may be required by the Authority.

20.6. Notwithstanding the above, the Authority shall have the power to call for such information, records or documents relating to NPS Swasthya directly from the HBA(s), as it may deem necessary.

CHAPTER IV – HEALTH BENEFIT ADMINISTRATOR (HBA)

21. Empanelment of HBA

21.1. ANPI shall empanel HBAs in close conjunction with the Authority through a transparent, and objective process.

21.2. The empanelment criteria, evaluation methodology, standard agreements and material decisions relating to the empanelment of HBAs shall be formulated in consultation with the Authority.

21.3. ANPI shall maintain and publish the current panel of HBAs and shall place empanelment, review, suspension and termination decisions before the Authority.

21.4. The Authority may seek records, participate in or observe the evaluation process, require reconsideration or corrective action, and issue directions in the interest of subscribers and the orderly development of NPS Swasthya.

21.5. Only an HBA on the current ANPI panel may be engaged by PF for NPS Swasthya.

21.6. Empanelment of an HBA by ANPI shall not dispense with the requirement for a separate engagement agreement between the HBA and the PF.

22. Eligibility Criteria

An applicant desirous to act as an HBA shall fulfill the following eligibility criteria as on the day of making an application.

22.1. The applicant or its promoter shall be,–

(i). a body corporate incorporated under the Companies Act, 2013; and

(ii). in continuous operation for at least two years;

22.2. The applicant or its promoter shall have,–

(i). a net worth of at least rupees five crore, as on the last day of the preceding financial year.

Explanation.- Net worth means as defined under section 2(57) of the Companies Act, 2013;

(ii). an average annual turnover of at least rupees five crore during the three preceding financial years;

(iii). at least two years of relevant experience in healthcare, health-benefit administration or healthcare transaction processing; and

(iv). a valid ISO/IEC 27001 certification.

22.3. The applicant or its promoter shall demonstrate,–

(i). provider connectivity supported by at least 5,000 completed IPD and/or OPD transactions;

(ii). the capacity to process at least 5,000 transactions per month; and

(iii). a two way switch/ integration between the HBA and the TPA in order to have a seamless and smooth flow of data and exchange of information between the two systems at all times.

22.4. The applicant and its key personnel shall be a ‘fit and proper person’ as specified in the empanelment framework.

22.5. While filing the application for empanelment, the applicant shall disclose all relevant information including any action or legal proceedings initiated against it, its key personnel in the past including the pending proceedings, for any material breach or non-compliance by them of any law, rules, regulations, and directions of the Authority or of any other regulatory body or the Government.

22.6. The applicant shall inform the ANPI and the Authority of any changes in the information furnished at the time of making an application, within seven days of such change.

22.7. The HBA shall maintain secure, scalable and interoperable systems, tested APIs, annual vulnerability assessment and penetration testing by a CERT-In empanelled auditor, appropriate Indiabased processing or storage where prescribed by law, and tested business continuity and disaster recovery arrangements.

22.8. HBA shall, at all times, comply with the eligibility criteria specified in these guidelines and other requirements laid down under the empanelment framework.

23. Empanelment Process

23.1. ANPI shall invite applications in the form and manner specified under the empanelment framework.

23.2. ANPI shall verify documentary compliance with the minimum eligibility criteria and seek clarifications, wherever required.

23.3. Operational, provider-network, technology, cybersecurity, financial and fit-and-proper due diligence shall be completed before empanelment.

23.4. ANPI shall record the evaluation and the decision or recommendation in accordance with the empanelment framework.

23.5. Before commencement of operations, the HBA shall execute the agreement and service level agreement and complete end-to-end user acceptance, security, load and business-continuity testing.

24. Engagement Agreement and Service Level Standards

24.1. The HBA engagement agreement shall contain written provisions relating to scope of services, measurable service levels, fees, confidentiality, information security, data roles, business continuity, incident reporting, records, audit rights, conflicts of interest, intellectual property, indemnity, liability, dispute resolution, termination and transition.

24.2. The minimum service standards shall be as specified in the Table below or otherwise prescribed by the Authority. A PF may prescribe stricter standards but shall not dilute the minimum standards.

SLA	Minimum standard	Measurement
Platform uptime	At least 99.5% in each calendar month	Monthly
API response	95th percentile within 1 second	Monthly
Planned IPD corpus authorization	Within 1 working hour of receipt of complete documentation	Per transaction
HBA-to-insurer/TPA referral	Within 5 minutes of a complete request meeting the trigger	Per transaction
Status synchronization	Update within 5 minutes of receipt of status	Per transaction
Document-once	No repeat request for a document already available, unless necessity for such request is recorded	Per transaction
Settlement intimation	Within 7 working days of receipt of final billing documents, for the NPS Swasthya corpus	Per transaction
HBA-service grievances	At least 90% resolved within 7 working days and 100% resolved within 15 working days	Monthly
Material incident	Initial report within 24 hours and detailed report within 7 days, subject to any stricter legal requirement	Event based

25. Core Responsibilities of HBA

An HBA engaged under NPS Swasthya shall,–

25.1. facilitate healthcare benefits and healthcare-related services in accordance with these Guidelines and the agreement with the PF;

25.2. facilitate verification and processing of healthcare-related requests and supporting documents submitted by subscribers, hospitals or healthcare service providers, as applicable;

25.3. verify withdrawal eligibility, the applicable withdrawal limit and available corpus, eligibility of healthcare expenses and the amount payable through the NPS Swasthya corpus in accordance with these guidelines;

25.4. provide the information required for balance verification, lien marking, redemption and settlement of eligible healthcare expenses and facilitate the settlement thereof through the prescribed process;

25.5. communicate the amount payable through NPS Swasthya to the concerned hospital or healthcare service provider, as applicable;

25.6. maintain adequate technological, operational and information-security arrangements, including appropriate access controls, for discharge of its responsibilities;

25.7. facilitate the subscriber-facing digital interface for the healthcare journey under NPS Swasthya and provide accurate information relating to eligibility for withdrawal, available balance, authorisation and transaction status;

25.8. maintain an accurate transaction trail and facilitate reconciliation of each healthcare encounter under the NPS Swasthya;

25.9. maintain appropriate controls to prevent and detect duplicate, fraudulent or anomalous healthcare requests and transactions;

25.10. ensure grievance redressal at the first instance in respect of services provided by the HBA and facilitate resolution of other healthcare-related grievances by routing them to the responsible entity, as applicable;

25.11. protect subscriber and health data and ensure confidentiality, security and access to such data only for authorised NPS Swasthya purposes;

25.12. maintain such records and transaction information as may be required for discharge of its responsibilities under these Guidelines and provide access to such records to the PF, ANPI, the Authority or an authorised entity by the Authority, as applicable;

25.13. submit such operational, financial, audit, security and incident reports as may be specified by ANPI, the PF or the Authority; and

25.14. act honestly, fairly, professionally and with due skill, care and diligence and shall not solicit or advise on insurance, guarantee payment of an insurance claim, steer subscribers to healthcare service providers for any undisclosed benefit, levy any unauthorised charge or use subscriber or health data for unrelated marketing or profiling.

25.15. Accountability for functions assigned to the HBA shall remain with the HBA and shall not be delegated in a manner that dilutes its responsibility under these Guidelines.

26. Monitoring, Review and Corrective Action

26.1. Empanelment of an HBA shall be subject to periodic review of its eligibility, fit-and-proper status, financial soundness, ISO/IEC 27001 certification, service levels, data quality, grievances, security controls and HBA performance.

26.2. For non-compliance, ANPI may, after consultation with the Authority, issue a warning, require a time-bound remediation plan, suspend the HBA or terminate empanelment.

26.3. Except where immediate interim action is necessary to protect subscribers, funds, data or system integrity, the HBA shall be given a reasonable opportunity to respond before an adverse empanelment decision is taken.

26.4. The Authority may inspect or require an independent audit of the HBA’s functions under NPS Swasthya.

27. Suspension, Termination and Orderly Transition

27.1. In case of suspension or termination, an HBA shall ensure continuity of services to existing subscribers and shall not adversely affect pending NPS Swasthya transactions.

27.2. The HBA shall protect subscriber data and securely transfer pending transactions, records and operational responsibilities to an alternate empanelled HBA engaged by the PF, within the period specified by ANPI in consultation with the Authority.

27.3. The transition and migration shall be completed securely and in accordance with applicable law, the engagement agreement and directions issued by the Authority.

28. Compliance with Directions

28.1. The HBA shall comply with the reporting requirements, operational standards and directions issued by the Authority in relation to its functions under NPS Swasthya.

28.2. The HBA shall ensure that its systems, personnel, processes and arrangements remain compliant with the applicable provisions of the Act, regulations, these Guidelines and the directions issued by the Authority from time to time.

CHAPTER V – INSURANCE POLICY

29. Insurance Policy

29.1. Every PF offering NPS Swasthya shall arrange a standard super top-up health insurance policy through an insurer registered with IRDAI, as specified under Clause of 30 & 31 of these guidelines.

29.2. The Insurance Policy shall be issued under a master policy or other group arrangement permitted under applicable insurance law. PF shall ensure that each subscriber or covered member is provided with the insurance policy, certificate of insurance, customer information sheet and other insurance related documents.

29.3. Before availing the services of an insurer, the PF shall evaluate the insurer based on, inter-alia, the scope of super top-up health insurance policy, servicing standards, claims administration, premium remittance, data sharing, grievance handling, reporting obligations and other operational matters. The PF shall also enter into an appropriate arrangement with the insurer to monitor the implementation and servicing of the insurance policy.

29.4. Insurance policy under NPS Swasthya shall commence not later than T+1 working days from the date of successful enrolment of the subscriber under NPS Swasthya and receipt of the applicable minimum initial contribution, where T denotes the date of successful enrolment.

29.5. The PF shall ensure that the insurance policy remains valid for as long as insurance benefits are offered under NPS Swasthya and shall provide for orderly transition in the event of a change of insurer.

29.6. Renewal and continuity, including waiting-period, migration, portability and moratorium credits, shall be governed by applicable insurance law and IRDAI directions. A PF initiated change of insurer shall be so undertaken in order to avoid break in cover.

29.7. Before enrolment, all material terms of the insurance policy, including sum insured, Annual Aggregate Deductible, exclusions, waiting periods, premium, renewal conditions, underwriting requirements, claim process and grievance redressal mechanism, shall be disclosed to the subscriber.

29.8. A PF shall not onboard an insurer-specific version of the Insurance Policy that differs from the standard Insurance Policy.

30. Standard Insurance Policy

30.1. Eligibility and cover

(i). Master policyholder: the PF, where permitted under applicable insurance law.

(ii). Coverage unit: subscriber, spouse and up to two dependent children as one family floater; parents are excluded.

(iii). Subscriber entry age: 18 to 70 years. Entry-age premium cohorts: 18 to 40 years; above 40 to 60 years; above 60 to 70 years. Renewal may continue up to and including age of 85 years, subject to premium, policy terms and applicable law.

(iv). The Annual Aggregate Deductible shall apply to cumulative Insurance – Admissible Expenses of all covered family members during the Policy Year and shall not apply separately to each claim.

Annual Aggregate Deductible	₹ 10,000	₹ 50,000	₹1 lakh	₹3 lakh
Family Floater Sum Insured	₹1 lakh	₹5 lakh	₹10 lakh	₹30 lakh

(v). Room entitlement: single private room for normal hospitalisation; ICU charges at actuals, subject to sum insured and the final policy wording.

(vi). Pre-hospitalisation: 30 days. Post-hospitalisation: 60 days. Road ambulance: up to ₹2,500 per emergency hospitalisation, unless a higher uniform limit is provided in the final policy.

(vii). The policy shall cover medically necessary day-care procedures, inpatient hospitalisation, domiciliary hospitalisation, AYUSH treatment, prescribed modern treatments and organ-donor medical expenses, subject to the final policy wording.

(viii). No co-payment or disease-specific sub-limit shall apply. Consumables and non-payables shall be as per the standard top-up insurance policy;

(ix) an Eligible Healthcare Expense not paid by insurance may be considered from the NPS Swasthya corpus.

30.2. Waiting periods, underwriting and continuity

(i). Initial waiting period: 30 days, except for accident as provided in the final policy wording.

(ii). Pre-existing disease waiting period: 12 months.

(iii). Specified disease or procedure waiting period: 12 months, subject to the final Insurance Policy and applicable insurance law.

(iv). Controlled Type 2 diabetes, hypertension, hyperlipidaemia and asthma that do not trigger enhanced underwriting under the prescribed Good Health Declaration shall be covered after the initial waiting period of 12 months.

(v). Fresh underwriting at renewal shall not be imposed except where sum insured is enhanced.

(vi). Waiting-period, migration, portability, moratorium and other continuity credits shall be carried forward on change of insurer and/or PF in accordance with insurance law and IRDAI directions.

(vii). An insurance decision based on material non-disclosure shall not by itself bar payment of a genuine Eligible Healthcare Expense from the NPS Swasthya corpus. A fabricated or fraudulent healthcare request shall not be paid from the corpus.

30.3. Good Health Declaration

(i). Insurance enrolment shall ordinarily be based on the prescribed Good Health Declaration.

(ii). Subscriber shall answer for himself/herself and on behalf of his/her spouse and his/her dependent children, whether he/she or any of family member/s 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 conditions, subject to the final question set permitted under the IRDAI-approved or filed policy:

S. No.	Condition
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.

(iii). Where a declaration triggers enhanced underwriting, the insurer shall apply the applicable premium loading based on the declaration, without requiring formal medical reports. Where the proposal is declined, the subscriber shall be communicated the specific reason for such decline in accordance with applicable law. Decline of coverage in respect of one family member shall not, by itself, disqualify other eligible family members, subject to the terms of the Insurance Policy.

30.4. Minimum claims and service controls

Service	Minimum requirement
Cashless pre-authorisation	Within one hour of a complete request, or any stricter applicable IRDAI timeline.
Final discharge authorisation	Within three hours of a complete hospital request, or any stricter applicable IRDAI timeline.
HBA referral/status synchronisation	Referral within 5 minutes and status update within 5 minutes of receipt.
Reimbursement target	Within 15 calendar days of the last necessary document, subject to the applicable IRDAI timeline.
Documents	Required hospital or insurance documents to be collected through the insurer/TPA process; subscriber document-once principle to apply.
Adverse decision	Specific policy clause, standard reason code, amount calculation and appropriate grievance route.

31. Insurance Premium

31.1. The insurer shall determine premium in accordance with the IRDAI framework. For Scheme comparability, premium shall be quoted for the entry age cohorts 18 to 40 years, above 40 to 60 years, and above 60 to 70 years, based on completed age at initial entry.

31.2. The insurer’s quote for premium shall include insurer and TPA costs; applicable taxes shall be shown separately. No mid-term premium revision shall apply to an issued policy except as permitted by applicable insurance law.

31.3. Renewal premium changes shall be governed by the applicable insurance law and shall not be imposed merely because an individual subscriber made a claim.

31.4. The first-year premium shall be paid upfront as part of the minimum initial funding requirement and remitted to the insurer through the prescribed fund-flow process as given in the SoP.

31.5. Renewal premium may be funded from the NPS Swasthya corpus and as per the subscriber mandate in accordance with these guidelines. The amount shall be remitted to the insurer through the prescribed fund-flow process as given in the SoP.

31.6. The PF shall maintain controls and advance alerts so that avoidable operational delay in premium remittance does not interrupt cover.

CHAPTER VI – CENTRAL RECORDKEEPING AGENCY (CRA), TRUSTEE BANK AND POINT OF PRESENCE (PoP)

32. Responsibilities of CRA

32.1. Provide the technology and recordkeeping support required for implementation and operation of NPS Swasthya in accordance with these guidelines.

32.2. Facilitate onboarding and registration of subscribers and open and maintain the NPS Swasthya account under the PRAN.

32.3. Maintain records of the PF, HBA, scheme mapping, contributions, units, NAV, own-contribution, healthcare withdrawals, premium mandates, nominations, exits and other details related to NPS Swasthya.

32.4. Facilitate transmission of relevant subscriber, account, insurance and transaction-related information among the PF, insurer, HBA and other entities, as may be required for operation of NPS Swasthya.

32.5. Facilitate processing of healthcare withdrawal and exit requests, including transmission of instructions relating to lien marking, redemption and settlement, in accordance with the approved process.

32.6. Record healthcare withdrawal, redemption, premium instruction and settlement transactions in the subscriber’s statement and other applicable records.

32.7. Provide subscriber access to account information, transaction confirmations and statements as prescribed.

32.8. Route grievances related to NPS Swasthya (excluding insurance policy) through the applicable PFRDA grievance mechanism and provide information required by the PF for resolution.

32.9. Reconcile the transactions related to NPS Swasthya, with the PF, Trustee Bank and HBA in accordance with these guidelines and report material exceptions, incidents or unauthorised instructions promptly.

32.10. Provide such information, records and reports relating to NPS Swasthya as may be required by the Authority; and

32.11. Undertake such other functions as may be specified by the Authority from time to time.

33. Responsibilities of Trustee Bank

33.1. Receive and account for contributions relating to NPS Swasthya and transfer funds for investment in accordance with valid instructions under the NPS architecture.

33.2. Execute only duly validated and authorised fund instructions for investment, premium remittance, healthcare settlement, corpus transfer and exit.

33.3. Remit amounts for settlement of claims to the designated hospital, healthcare provider, subscriber or other approved payee in accordance with the CRA instruction.

33.4. Remit insurance premium in accordance with these guidelines.

33.5. Maintain appropriate records of receipts, transfers, redemptions and payments relating to NPS Swasthya;

33.6. Undertake reconciliation of transactions relating to NPS Swasthya with the CRA, PF and other concerned entities, as may be required; and

33.7. Furnish such information, records and reports as may be required by the Authority.

34. Responsibilities of Point of Presence

34.1. The Point of Presence shall perform such functions in relation to NPS Swasthya as may be specified by the Authority from time to time.

34.2. The PoP shall comply with the applicable provisions of the Act, regulations, these Guidelines and directions issued by the Authority in relation to activities undertaken under NPS Swasthya.

CHAPTER VII – TECHNOLOGY, SUBSCRIBER DISCLOSURE AND GRIEVANCE REDRESSAL

35. Technology and Operational Framework

35.1. All participating entities shall implement the architecture and process-flows prescribed for NPS Swasthya and complete end-to-end user acceptance, security, load, disaster-recovery and negativescenario testing before go-live for each operating combination.

35.2. The HBA shall provide the single digital front for healthcare status and coordination.

35.3. Data sharing shall be necessary, proportionate, purpose-specific and based on recorded consent or another lawful basis. Health data shall not be used for unrelated marketing, profiling or provider steering. Applicable cybersecurity, data-protection, localisation, encryption, access-control and retention requirements shall be followed.

35.4. The PF shall ensure seamless integration of the systems of the PF, CRAs, Trustee Bank, HBAs, insurers and other participants for onboarding, account servicing, insurance administration, healthcare benefit administration, withdrawals, redemption, settlement and grievance redressal.

35.5. All participating entities shall establish appropriate controls to ensure accuracy, security, confidentiality, integrity and timely transmission of information and settlement of funds.

35.6. A material cybersecurity, privacy, availability or payment incident shall be contained, notified, investigated and remediated in accordance with the applicable PFRDA, CERT-In and data-protection requirements, having regard to the regulatory responsibility of the affected entity.

35.7. The PF shall ensure appropriate reconciliation of information and fund flows among the CRA, Trustee Bank, PF, HBA, insurer and other concerned entities.

35.8. The PF shall ensure that appropriate audit trails are maintained for all material information and fund-flow transactions undertaken under NPS Swasthya.

36. Disclosures

36.1. The PF shall ensure that every subscriber receives complete, accurate, clear and timely information about NPS Swasthya before enrolment and throughout the tenure of the account.

36.2. Before activation and at each renewal, the subscriber shall receive copy of PRAN card, details of HBA, details of Insurer, details of TPA and insurance policy related documents.

36.3. Disclosures shall clearly cover, including but not limited to, initial contribution, charges related to NPS Swasthya, super top-up health insurance policy benefits, insurer, TPA, premium, deductible, exclusions, waiting period, insurance variants and deductible, family coverage, claims process and grievance redressal mechanism.

36.4. Insurance premium and taxes shall be shown separately from NPS Swasthya account charges.

36.5. The subscriber shall be informed of a material change as early as practicable and before it takes effect where advance notice is possible. Any insurance change shall also be communicated in the manner required under applicable insurance law and the Insurance Policy.

36.6. Every adverse decision under NPS Swasthya shall be displayed and conveyed to the subscriber along with applicable reason in plain language and state the appropriate escalation route.

37. Grievance Redressal

37.1. The subscriber shall be able to lodge a grievance through the Pension Sahayak platform which will enable subscribers to lodge grievances against any stakeholder namely PF, CRAs, POPs, HBAs, Insurers, etc for quick and effective resolution of its grievance.

37.2. The PF shall establish an effective mechanism for redressal of grievances relating to NPS Swasthya. Where a grievance pertains to services rendered by an HBA and insurer engaged under NPS Swasthya, the PF shall coordinate with the concerned entity to facilitate timely resolution.

37.3. The PF shall monitor the resolution of grievances and ensure compliance with the timelines specified by the Authority.

37.4. The insurer shall be responsible for grievance redressal arising out of claim settlement process and any incidental matters to super top-up health insurance policy, in terms of applicable IRDAI Regulations.

37.5. The HBA shall provide a single grievance reference for grievances relating to the healthcare journey and shall coordinate with the concerned entity, as applicable, and remain responsible for closure and escalation in relation to the HBA services.

CHAPTER VIII – REPORTING, COMPLIANCE AND REGULATORY POWERS

38. Regulatory Reporting

38.1. The PF shall furnish periodic reports to the Authority on enrolment, contributions, withdrawals, exits, HBA performance, integrated service levels and such information as is necessary to assess operation of NPS Swasthya.

38.2. The PF shall furnish such returns, reports and information relating to NPS Swasthya as may be required by the Authority from time to time.

38.3. Every intermediary engaged under NPS Swasthya shall furnish such reports and information as may be required by the Authority in such form and manner and within such time as may be specified.

38.4. ANPI may maintain HBA-wise and insurer-wise operational dashboards using common definitions and without personal data. Comparable service metrics may be published in the manner specified by the Authority.

38.5. HBA eligibility failure, persistent service slippage, data misreporting, subscriber harm, cybersecurity failure or failure to implement corrective action shall be reported promptly to the Authority.

39. Compliance

39.1. Every PF shall ensure compliance with these Guidelines and the conditions imposed by the Authority for NPS Swasthya.

39.2. The PF shall maintain adequate internal controls, risk management, audit, business continuity and monitoring arrangements for effective implementation of NPS Swasthya.

39.3. Every PFRDA-regulated intermediary participating in NPS Swasthya, ANPI and HBA shall comply with the provisions of these Guidelines and with the directions issued by the Authority.

39.4. The insurer and TPA shall comply with their participation agreement and common operating protocol to the extent consistent with applicable insurance law and the Insurance Policy.

40. Power to Call for Information

40.1. The Authority may require a PF or any PFRDA-regulated intermediary participating in NPS Swasthya to furnish such information, records, data or documents as it considers necessary.

40.2. The Authority may call for records directly from an HBA in relation to the functions performed by it under NPS Swasthya.

40.3. Where information held by an insurer or TPA is necessary for reconciliation, scheme servicing or subscriber protection, the PF shall obtain and furnish such information to the Authority, subject to applicable law.

41. Power to Issue Directions and Interpretation

41.1. The Authority may issue directions, clarifications or instructions to PFs, PFRDA-regulated intermediaries, ANPI and HBAs for effective implementation of the NPS Swasthya and protection of subscribers’ pension interests.

41.2. Any question relating to interpretation of these Guidelines shall be decided by the Authority.