Ayushman Bharat (PMJAY)

Key decisions

1. Q1

   Am I eligible for Ayushman Bharat?

   Eligibility is SECC-2011 (Socio Economic Caste Census) based, NOT income-test. Auto-eligible if family meets any 1 of 7 rural deprivation criteria OR is in 1 of 11 occupation-based urban categories (daily wage, sanitation worker, domestic help, etc.). Verify at pmjay.gov.in → 'Am I Eligible' → enter mobile + state. Many salaried Indians are NOT eligible directly but their parents (if owning < ₹50L assets + no salaried child in same household) may qualify under state expansions. Note: 14 states (Maharashtra, Karnataka, Tamil Nadu, Punjab, etc.) have EXPANDED universal coverage above PMJAY — check your state scheme via state-health-department website.

2. Q2

   What does Ayushman Bharat actually cover?

   ₹5L per FAMILY per year (NOT per person — entire family share the cap). Covers: secondary care + tertiary care hospitalisation, pre-existing diseases from Day 1 (NO waiting period — unique vs private insurance), 1,500+ medical procedures including surgeries, dialysis, chemotherapy. Includes: room charges (general ward), doctor consultations, drugs, diagnostics, ICU. NOT covered: outpatient consultations (OPD), cosmetic surgery, fertility treatments, organ transplants (some states added). Cashless treatment at empanelled hospitals only — check pmjay.gov.in/hospitals for your nearest 27,000+ network options.

3. Q3

   How does Ayushman Bharat work with private health insurance?

   LAYER strategy: Ayushman Bharat as base (₹5L cashless), private as supplement (₹10-25L). Most major Indian hospitals are EITHER in PMJAY network OR private network — rarely both. Use cases: (1) Tier-2/3 city emergency in PMJAY-empanelled district hospital = use Ayushman Bharat first, exhaust it, then private for residual; (2) Metro city treatment in private corporate hospital = private insurance only (PMJAY rarely empanels Apollo/Fortis/Max etc.); (3) Chronic illness with multiple hospitalisations in same year = critical to have both. CRITICAL: at admission, you MUST choose ONE — can't claim from both for the same hospitalisation. Sub-letting risks: some private hospitals empanel for PMJAY but offer worse rooms / older medical equipment.

4. Q4

   How do I get my Ayushman Bharat e-card?

   FREE, takes 7-15 days. Two routes: (1) Visit nearest Common Service Centre (CSC) — they verify SECC eligibility via Aadhaar, issue PVC card. ₹30 service fee at CSC. (2) Self-service at pmjay.gov.in: 'Apply for Ayushman Card' → Aadhaar OTP → upload photo → download e-card PDF immediately. Card is per-family, lists all members. Mandatory documents: Aadhaar (family head + each member), ration card (helps), mobile number. If SECC-eligible but no card issued in 30 days, escalate via PMJAY 14555 helpline. Newborns added free within 6 months of birth via the family head's card.

5. Q5

   What state-government schemes add to Ayushman Bharat?

   14 states have expanded coverage beyond PMJAY's ₹5L cap. TOP: Mahatma Jyotirao Phule Jan Arogya Yojana (Maharashtra) — adds ₹2L per family (total ₹7L). Chiranjeevi Yojana (Rajasthan) — UNIVERSAL coverage ₹10L. Aarogyasri (Andhra/Telangana) — ₹5L additional for BPL families. Karunya Health Scheme (Kerala) — covers PMJAY + select critical illnesses for additional ₹3L. Mukhyamantri Amrutum (Gujarat) — ₹3L additional. Apply via your state health department portal — typically auto-enrolled if you have PMJAY card. Check status at state-scheme portal (varies by state). Bonus: most states cover OPD consultations + diagnostics that PMJAY doesn't.

Top insurers ranked by claim settlement

• PMJAY (Central Govt):World's largest health scheme. ₹5L cashless cover, 27,000+ hospitals, pre-existing covered Day 1. Free — apply at pmjay.gov.in.
• HDFC Ergo Optima Restore:Best private complement — ₹10-50L cover, 12,000+ network hospitals, restoration benefit.
• Star Health Senior Citizen Red Carpet:Best for parents 60+ not eligible for PMJAY. ₹5-25L with pre-existing covered after 1 year.
• Niva Bupa ReAssure:Strong supplementary cover with no claim-based premium loading + ₹10-50L options.
• ICICI Lombard Complete Health:Best for metros — Apollo/Fortis/Max network coverage where PMJAY rarely empanels.