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—guide:applicant:application:sample:ayushman-bharat [2026/06/03 17:01] (current) – created - external edit 127.0.0.1
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 +{{htmlmetatags>metatag-keywords=(RTI for Ayushman Bharat,PMJAY claim denial RTI,golden card RTI,empanelled hospital denial,National Health Authority RTI,State Health Agency RTI,PMJAY pre-authorisation,sample RTI India 2026)
 +metatag-description=(PMJAY claim denied or hospital refused cashless treatment? Free RTI to NHA or SHA. Sample letter, first appeal text, sources, FAQs. Citizen guide 2026.)}}
 +
 +====== Sample RTI: Ayushman Bharat PMJAY Hospital Denial and Treatment Authorisation ======
 +
 +{{:icons:shield.svg?24&nolink|Shield}}
 +
 +<WRAP center round tip 100%>
 +**Direct answer.** If a PMJAY hospital denied cashless treatment, your golden card is stuck, or your pre-authorisation has been rejected, file a free RTI to the **PIO of your State Health Agency (SHA)** with a copy to the **National Health Authority (NHA)** and the **empanelled hospital**. Reply due in 30 days, or **48 hours** under the life-or-liberty proviso to Section 7(1). Fee: Rs 10 (BPL applicants: nil under Section 7(5)).
 +</WRAP>
 +
 +===== When to use this RTI =====
 +
 +  * 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.
 +
 +===== When NOT to use this RTI =====
 +
 +  * **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.
 +
 +===== Drafting notes =====
 +
 +  * 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.
 +
 +===== Privacy caution =====
 +
 +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.
 +
 +===== Sample format =====
 +
 +<code>
 +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    : ___________________
 +</code>
 +
 +===== First appeal wording =====
 +
 +<code>
 +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    : ___________________
 +</code>
 +
 +===== Sources =====
 +
 +  * [[https://pmjay.gov.in|pmjay.gov.in]]: Pradhan Mantri Jan Arogya Yojana, scheme portal.
 +  * [[https://nha.gov.in|nha.gov.in]]: National Health Authority.
 +  * [[https://grievance.pmjay.gov.in|grievance.pmjay.gov.in]]: PMJAY central grievance portal.
 +  * [[https://mohfw.gov.in|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).
 +
 +===== FAQs =====
 +
 +==== Hospital is recovering money from me though I have a golden card. What now? ====
 +
 +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.
 +
 +==== What does "pre-authorisation rejection" mean? ====
 +
 +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.
 +
 +==== Is the empanelment list public? ====
 +
 +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.
 +
 +==== Can I file an RTI with the hospital itself? ====
 +
 +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.
 +
 +==== What if treatment is in progress? ====
 +
 +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.
 +
 +===== Internal links =====
 +
 +  * [[https://righttoinformation.wiki/tools/ai-rti-draft-app.html|AI RTI Drafter]]: builds a customised letter in 60 seconds.
 +  * [[guide:applicant:application:sample:start|Sample RTI index]]: full library.
 +  * [[guide:applicant:first-appeal|First appeal guide]]: Section 19(1) procedure.
 +  * [[guide:applicant:application:sample:hospital-records|Sample RTI: government hospital records]]: clinical cousin.
 +  * [[guide:applicant:application:sample:udid-disability-certificate|Sample RTI: UDID disability card]]: cousin benefit-linked sample.
 +  * [[guide:applicant:application:sample:pension|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.//
 +
 +{{tag>rti sample-rti ayushman-bharat pmjay nha sha health applicant}}