RTI If Your Ayushman Bharat (PMJAY) Claim Is Rejected or Delayed

You carried your Ayushman card to the hospital. The hospital told you that you are on the PMJAY panel and that your treatment would be covered. Then the pre-authorisation was denied, or the cashless claim was rejected, or the hospital told you at discharge that the claim had not gone through and that you would have to pay out of pocket. Or you discovered that someone had already made a claim against your beneficiary ID — for treatment you never received.

Every one of these situations is a documented government decision, made by a named officer, recorded in a system maintained by the National Health Authority or your state's health agency. The Ayushman Bharat — Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a centrally funded government health insurance scheme. The authorities implementing it are public authorities under Section 2(h) of the Right to Information Act, 2005. The decisions they make about your claim are subject to RTI.

Under Section 6 of the RTI Act, you can demand the exact basis of the rejection, the name and designation of the officer who approved it, and the file behind the decision — within 30 days under Section 7(1). This guide tells you exactly how.

The Architecture of AB-PMJAY: Who Is Responsible for What

Understanding the implementing structure of AB-PMJAY is essential for directing your RTI to the right authority.

National Health Authority (NHA): The NHA, under the Ministry of Health and Family Welfare (MoHFW), is the apex body responsible for AB-PMJAY at the national level. It sets empanelment standards for hospitals, manages the technology platform, releases central funds to states, and handles national-level policy and audit. The NHA is a Central Government body — RTI to NHA is filed via rtionline.gov.in, and the Second Appeal under Section 19(3) lies with the Central Information Commission (CIC).

State Health Agency (SHA): Each state has a State Health Agency (sometimes called the State Nodal Agency or State Health Assurance Society) that implements AB-PMJAY within the state. The SHA empanels hospitals, processes claims, monitors fraud, and disburses payments to hospitals. State Health Agencies are state government bodies — RTI to the SHA is filed with the state's PIO or through the state's RTI portal. The Second Appeal under Section 19(3) lies with the State Information Commission (SIC) of that state.

District Implementation Unit (DIU): In many states, the SHA operates through District Implementation Units, which handle day-to-day beneficiary verification, Ayushman card generation, and ground-level grievances. The DIU-level PIO is the most accessible entry point for beneficiary-specific queries.

For most individual claim issues — rejection of pre-authorisation, cashless claim denial, hospital de-empanelment — the SHA or its District Implementation Unit is the most relevant and most useful authority to file RTI with. For national-level data (such as whether a specific hospital was suspended across India, or the national claim approval rate for a specific procedure), RTI to the NHA is more appropriate.

The application fee is ₹10 under the RTI (Regulation of Fee and Cost) Rules, 2005. BPL cardholders are exempt under Section 7(5) — which is directly relevant here, since AB-PMJAY beneficiaries belong to economically weaker sections who qualify for this exemption.

Scenario 1: Your Name Is Not in the PMJAY Beneficiary Database

You were told you qualify for AB-PMJAY — based on your SECC (Socio-Economic and Caste Census) data or your state's equivalent beneficiary identification — but when the hospital checks your Aadhaar or family ID, your name does not appear. Or you received an Ayushman card earlier and it now shows as inactive.

AB-PMJAY beneficiary eligibility is determined at the central level based on SECC-2011 data for the initial roll, supplemented by state-specific additions. If your name should be there but is not, RTI can surface whether the issue is a data entry error, a category mismatch, or a deliberate exclusion.

Sample RTI questions:

"1. Whether the household with Aadhaar number X / ration card number X / SECC family ID X appears in the AB-PMJAY beneficiary database for district/state. If not, state the basis on which the household was excluded from the beneficiary list."

"2. The criteria applied for determination of AB-PMJAY beneficiary eligibility in state for the financial year X. Specifically, whether SECC-2011 deprivation categories, NFSA ration card holders, or additional state-specific categories were used, and which category the household with identifier falls under or was found not to fall under."

"3. Whether any grievance or correction request for inclusion of the household of name, Aadhaar number X, has been received by the SHA / District Implementation Unit of district. If yes, its current status and the action taken."

"4. The name and designation of the officer responsible for the AB-PMJAY beneficiary database administration at the District Implementation Unit of district."

Scenario 2: Pre-Authorisation Request Denied

Pre-authorisation (also called prior-approval) is required for certain procedures under AB-PMJAY before the hospital can proceed with cashless treatment. The SHA's claims processing team reviews the pre-auth request and approves or denies it based on clinical criteria. When pre-authorisation is denied, the beneficiary is often told only that "the request was not approved" — without being given the medical or administrative grounds.

This is the most common point of opaque decision-making in PMJAY. RTI can force the SHA to state the recorded grounds — and in many cases, the stated grounds reveal a procedural error, a miscoding of the procedure, or a clinical guideline that was misapplied.

Sample RTI questions:

"1. The reason for rejection of pre-authorisation request bearing reference number X, submitted by hospital name for beneficiary name / PMJAY ID number on date for the procedure name of procedure / package code. State the specific medical or administrative grounds recorded for rejection, and cite the clinical protocol or policy document on which the rejection was based."

"2. The name, designation, and qualification of the officer or reviewer who approved the rejection of pre-authorisation request number X."

"3. Whether the hospital's treatment request for the above pre-authorisation was reviewed by a medical officer before rejection, and if yes, the name and designation of that medical officer."

"4. Whether pre-authorisation for the same procedure — procedure name / package code — has been approved for other AB-PMJAY beneficiaries in state in the current financial year. If yes, provide the number of such approvals and the criteria applied."

"5. The time taken from submission to rejection of pre-authorisation request number X, and whether this complied with the turnaround time prescribed under the SHA's pre-authorisation policy."

Scenario 3: Cashless Claim Rejected After Treatment

When a claim is submitted by the hospital after treatment and is rejected by the SHA or its Third Party Administrator (TPA), the hospital often passes the rejection on to the patient as a bill. This is a direct financial harm to the beneficiary. RTI can get you the exact grounds of rejection and, crucially, whether the hospital committed a procedural error in filing the claim (in which case the hospital, not you, bears responsibility) or whether the SHA made a wrong call.

Sample RTI questions:

"1. The reason for rejection of cashless claim reference number X submitted by hospital name for beneficiary name / PMJAY ID for treatment during the period dates. State the specific grounds — medical, procedural, or documentary — recorded for rejection."

"2. Whether the package code claimed by hospital name for the treatment of beneficiary name / PMJAY ID was listed as an approved package under AB-PMJAY at the time of treatment. If the claim was rejected on the ground that the package code was incorrect, state which package code the SHA determined was applicable."

"3. Whether the hospital name was empanelled under AB-PMJAY on the dates of treatment dates. If the claim was rejected on the ground of hospital empanelment status, provide the dates of empanelment and any suspension or de-empanelment."

"4. A copy of the claim rejection notice or order issued to hospital name for claim reference X, including the rejection code and the reviewing officer's name and designation."

"5. Whether hospital name has filed an appeal or grievance against the rejection of claim reference X with the SHA, and if yes, the status of that appeal."

Scenario 4: Hospital De-Empanelled Mid-Treatment

A hospital can be de-empanelled by the SHA for fraud, overcharging, or non-compliance — sometimes while a beneficiary is mid-way through a course of treatment. If this has happened to you, RTI can establish when the de-empanelment took effect, the reason for it, and whether the SHA was required to ensure continuity of care for beneficiaries already admitted.

Sample RTI questions:

"1. The date on which hospital name, address was de-empanelled or suspended from the AB-PMJAY panel in state, and the reason for de-empanelment or suspension."

"2. A copy of the show-cause notice issued to hospital name before de-empanelment, and a copy of the hospital's response, if any."

"3. Whether AB-PMJAY beneficiaries who were undergoing treatment at hospital name at the time of de-empanelment on date were provided any alternative arrangement or protected under any continuity of care provision. If yes, the details of that arrangement."

"4. The total number of de-empanelment orders issued by the SHA for state in the financial year X, and the categories of violation most commonly cited."

Scenario 5: Fraudulent Claim Made in Your Name

One of the most serious problems in PMJAY is the filing of fraudulent claims — where a hospital, an agent, or an insider files a claim for treatment that the beneficiary never received, drawing down the beneficiary's covered amount. Beneficiaries often discover this only when they try to use their PMJAY card for a genuine hospitalisation and are told that their entitlement for the year has been exhausted.

This is a documented crime and a documented government failure. RTI can get you the complete claim history under your beneficiary ID — every claim filed, the hospital that filed it, the treatment date, the amount, and the claim approval officer — allowing you to identify and report fraudulent entries.

Sample RTI questions:

"1. Provide a complete list of all AB-PMJAY claims filed against PMJAY ID / family ID X / Aadhaar number X from the date of scheme commencement to date. For each claim: the hospital name and address, the treatment date, the package name and code, the claim amount, and the claim approval date."

"2. For each of the claims listed above, provide the name and designation of the SHA officer or reviewer who approved the claim."

"3. Whether any fraud complaint or alert has been registered in connection with claims under PMJAY ID / family ID X. If yes, the status of the investigation and the action taken."

"4. The mechanism by which the SHA verifies that the beneficiary named in a pre-authorisation request is actually present at the hospital and consenting to treatment, and whether this verification was performed for each of the claims under PMJAY ID X."

About Empanelled Private Hospitals and RTI

A question that arises frequently: can RTI be filed with the empanelled private hospital itself?

The general rule is that private companies are not public authorities under Section 2(h) of the RTI Act. However, Section 2(h)(d) includes bodies that are "substantially financed, directly or indirectly, by funds provided by the appropriate Government." There is a legal argument that private hospitals receiving large volumes of government money through PMJAY reimbursements may qualify — but this argument is contested and has not been settled by the courts for this specific context.

The reliable and consistently successful approach is to file RTI with the NHA or SHA — which does qualify as a public authority — for all information about claims, approvals, rejections, and empanelment. The SHA holds this data. The SHA processed the claim. The SHA approved or rejected the pre-authorisation. All the information you need about what happened with your PMJAY treatment is in the SHA's system, not just in the hospital's records.

Do not rely on the private hospital's goodwill to disclose information. File RTI with the SHA.

State Variations: Ayushman Bharat Plus State Schemes

Several states have layered their own health insurance schemes on top of AB-PMJAY, extending coverage beyond the national scheme's limits. Examples include Ayushman Bharat Arogya Karnataka (AB-ArK), Maulana Azad Bima Yojana (Telangana), Chief Minister Comprehensive Insurance Scheme (Tamil Nadu), Dr. YSR Aarogyasri (Andhra Pradesh), and others.

If your issue involves the state extension rather than the core AB-PMJAY package, file RTI with the State Health Agency for the state-specific scheme. These are state bodies; Second Appeal goes to the State Information Commission.

If the issue involves the core national PMJAY package, both NHA (central, → CIC) and SHA (state, → SIC) may hold relevant information. In most individual claim situations, the SHA's records are more directly relevant and more actionable.

Using the RTI Response

If the rejection reason reveals a procedural error by the hospital: Use the RTI response to formally object to any bill the hospital presents. If the claim was denied because the hospital submitted the wrong package code, or filed after the submission deadline, or failed to include required documentation, the error is the hospital's — not yours. Present the RTI response to the hospital's billing department and, if necessary, to the District Implementation Unit with a complaint.

If the rejection reason is a clinical grounds decision that appears wrong: Consult with the treating doctor and, if warranted, obtain a second medical opinion. The RTI response establishes the specific clinical grounds cited. A representation to the SHA's Medical Review Officer, attaching the treating doctor's opinion and the RTI response, gives the SHA documented basis to reconsider.

If fraudulent claims are confirmed: File a written complaint with the SHA's Vigilance and Anti-Fraud Cell, enclosing the RTI response. File a complaint with the police. In states where the scheme is administered under specific legislation, there may be criminal provisions specifically targeting PMJAY fraud.

If the CPIO does not respond within 30 days: File a First Appeal under Section 19(1) within 30 days of the expiry of the response period with the First Appellate Authority of the SHA or NHA. If the First Appeal is also unsatisfactory, file a Second Appeal under Section 19(3) — to the CIC for NHA-level matters, to the State Information Commission for SHA-level matters. The Section 20 penalty — ₹250 per day, up to ₹25,000 — is available against a PIO who failed to respond without reasonable cause.

How RTISathi Can Help

PMJAY claim rejections and fraudulent claims are among the situations where government documentation is critical and almost never voluntarily shared. The rejection notice issued to the hospital rarely reaches the beneficiary. The clinical grounds recorded by the SHA's reviewer are internal file notings. The claim history under a beneficiary ID is a system record the beneficiary cannot access online in full detail.

RTI changes this. A correctly framed application to the SHA's PIO or the NHA's CPIO forces that documentation into the open — with statutory deadlines and penalty consequences for non-compliance.

RTISathi.com can help you identify the correct public authority for your PMJAY situation, draft precise RTI questions targeting the specific information that will let you challenge a rejection or expose a fraudulent claim, and support the First and Second Appeal process if the initial response is inadequate. Your Ayushman card is a legal entitlement. If that entitlement was wrongly denied or fraudulently drawn against, the evidence is in a government system — and RTI is how you reach it.