Sample RTI: Ayushman Bharat PMJAY Hospital Denial and Treatment Authorisation

• Empanelled hospital refused cashless treatment despite a valid PMJAY card.
• Pre-authorisation rejected without reasons recorded on the BIS portal.
• Claim payment to hospital delayed; hospital recovering money from you.
• Golden card not issued despite eligibility on the SECC 2011 / Aspirational District list.
• Treatment package downgraded mid-treatment; balance demanded from patient.
• De-empanelment of a hospital mid-treatment without notice to the patient.
• Discharge against pre-authorisation specification.
• State top-up scheme benefit denied at PMJAY hospital.

• Private-hospital cashless dispute on private insurance: that is an IRDAI matter, not an RTI.
• Quick grievance: lodge on the PMJAY grievance portal at grievance.pmjay.gov.in first; the ticket is what your RTI then references.
• Asking for another beneficiary's claim file: refused under Section 8(1)(j); restrict to your own file.
• Compensation claim: file before the State Consumer Commission under the Consumer Protection Act, 2019.

• Quote your PMJAY ID and the golden card number.
• State the hospital name and empanelment ID, the admission date, and the package/procedure code.
• For pre-authorisation rejection, ask for the case-based reasoning recorded by the medical reviewer at the SHA / Insurer.
• For empanelment-related issues, ask for the Memorandum of Understanding (MoU) between the SHA and the hospital.
• If treatment is ongoing, invoke the 48-hour life-or-liberty proviso.
• Send by Speed Post (Acknowledgement Due) and by email to the PMJAY grievance cell to fix dual proof.

You may ask only for your own claim file, your own pre-authorisation record, and your own treatment history. The published list of empanelled hospitals, package rates, and policy notifications is public under Section 4(1)(b). A neighbour's PMJAY claim, another patient's surgery file, or a hospital-staff personnel record falls within Section 8(1)(j) and is protected.

To
The Public Information Officer
[State Health Agency name, e.g., Ayushman Bharat State Health Agency, [State]]
[Full postal address, PIN]

Copy to:
1. Public Information Officer, National Health Authority, New Delhi.
2. Public Information Officer, [Empanelled hospital name].

Subject: Application under Section 6(1) of the Right to Information Act, 2005:
       Records on PMJAY claim, pre-authorisation and empanelment

Sir / Madam,

1. I, [Full name], a citizen of India residing at [full address], apply under
   Section 6(1) of the Right to Information Act, 2005 for the records below.
   Where treatment is ongoing, this request invokes the proviso to Section
   7(1) for a 48-hour reply.

2. Particulars for record-identification:
       PMJAY ID / Golden Card No.   : ________________
       Patient name and relationship : ________________
       Hospital name and empanelment ID : ________________
       Admission / treatment dates  : ________________
       Package / procedure code     : ________________

3. Information sought (please supply certified copies):
   (a) Certified copy of my pre-authorisation request submitted by the
       hospital, with date and time-stamp on the BIS portal.
   (b) Certified copy of the medical-reviewer's notes and the basis of
       approval, partial approval, or rejection.
   (c) If rejected, the certified copy of the rejection order and the
       grounds in writing.
   (d) Certified copy of the claim file, including bill calculation, package
       break-up, and disallowed entries.
   (e) Empanelment status of the hospital on the date of admission and any
       de-empanelment notice issued thereafter.
   (f) Certified copy of the MoU between the SHA and the hospital, restricted
       to clauses on cashless treatment guarantee.
   (g) Compliance log of the hospital's grievance cell for my complaint, if
       any was filed.
   (h) Name, designation and office address of the officer presently holding
       my claim file.

4. I enclose Rs 10 by Indian Postal Order in favour of the Accounts Officer
   of the State Health Agency. (BPL: Section 7(5) exemption claimed.)

5. Please send the reply to the address below by Registered Post.

Yours faithfully,
Signature
Name    : ___________________
Address : ___________________
Date    : ___________________

To
The First Appellate Authority
[State Health Agency / National Health Authority]

Subject: First appeal under Section 19(1) of the Right to Information Act, 2005:
       Non-supply of records on PMJAY claim and authorisation

Sir / Madam,

1. I filed RTI dated [DD/MM/YYYY] (Speed Post No. [XXXX]) seeking the records
   listed therein. The request invoked the life-or-liberty proviso to
   Section 7(1) of the RTI Act, 2005.

2. The 30-day / 48-hour period expired on [DD/MM/YYYY]. The PIO has not
   replied / has replied incompletely on the following points: [list].

3. I therefore appeal under Section 19(1) and pray that the PIO be directed
   to supply the records sought within the time fixed by you.

4. I draw attention to Section 19(8)(a)(i) on costs and Section 20(1) on
   penalties.

Yours faithfully,
Signature
Name    : ___________________
Address : ___________________
Date    : ___________________

• pmjay.gov.in: Pradhan Mantri Jan Arogya Yojana, scheme portal.
• nha.gov.in: National Health Authority.
• grievance.pmjay.gov.in: PMJAY central grievance portal.
• mohfw.gov.in: Ministry of Health and Family Welfare.
• The Right to Information Act, 2005, Sections 6(1), 7(1), 7(5) and 19(1).

This is a prohibited practice under PMJAY guidelines. File the RTI immediately, attach the bill, and lodge a parallel complaint on grievance.pmjay.gov.in. The SHA can recover the amount from the hospital and pay you back; the empanelment can also be suspended.

The medical reviewer at the SHA / Insurer reviewed the hospital's request and decided the case is not covered (wrong package, exclusion, or eligibility issue). The RTI gives you the reasons in writing so you can appeal or escalate.

Yes. The list of empanelled hospitals is fully public on pmjay.gov.in under Section 4(1)(b). A specific MoU is also disclosable, but the SHA may redact bank-account / commercial-rate details under Section 8(1)(d) trade-secret carve-out.

A private hospital is not a public authority under RTI. But once it is empanelled under PMJAY, the SHA-held claim file and the BIS-portal record are with the public authority, so you file with the SHA. The hospital's internal record remains private.

Invoke the 48-hour proviso to Section 7(1) by stating clearly on the cover that the records concern ongoing treatment of yourself or a family member. Send by speed post and by email simultaneously.

• AI RTI Drafter: builds a customised letter in 60 seconds.
• Sample RTI index: full library.
• First appeal guide: Section 19(1) procedure.
• Sample RTI: government hospital records: clinical cousin.
• Sample RTI: UDID disability card: cousin benefit-linked sample.
• Sample RTI: pension: another beneficiary-record sample.

Last reviewed: 9 May 2026

Sources verified against the National Health Authority operational guidelines, the PMJAY scheme document, the Right to Information Act, 2005, and the official portals as on 9 May 2026.