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—guide:applicant:ayushman-bharat-denial-rti [2026/07/10 22:51] (current) – created - external edit 127.0.0.1
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 +{{htmlmetatags>metatag-keywords=(Ayushman Bharat RTI,PMJAY denial RTI,empanelled hospital RTI,SECC eligibility,NHA RTI,health insurance grievance,PMJAY treatment records)
 +metatag-description=(PMJAY hospital denied cashless treatment? File this RTI to NHA or SHA for empanelment status, package code log, pre-auth trail and grievance file movement.)}}
  
 +====== RTI for Ayushman Bharat Hospital Denial and PMJAY Treatment Records ======
 +
 +<WRAP center round tip 100%>
 +Pradhan Mantri Jan Arogya Yojana (PMJAY) is administered by the **National Health Authority (NHA)** at the centre and **State Health Agencies (SHAs)** at the state level. Empanelled hospitals must accept eligible beneficiaries cashless for the listed package, refusal is contractually and legally disallowed. An RTI under Section 6 of the RTI Act 2005 to NHA, the SHA and the District Implementing Unit normally produces the empanelment status, pre-auth trail, denial endorsement and grievance file within 30 days.
 +</WRAP>
 +
 +===== When to use this guide =====
 +
 +Use this guide if (a) an empanelled hospital denied cashless treatment despite a valid PMJAY card; (b) the hospital downgraded the package or asked you to pay; (c) pre-authorisation was rejected without reasons; (d) the SHA's grievance cell is not responding; (e) you want the SECC eligibility entry that links your name to PMJAY; (f) you want to know whether the hospital is even on the empanelled list.
 +
 +===== Legal basis =====
 +
 +  * **PMJAY Operational Guidelines** issued by NHA.
 +  * **Tripartite Agreement** between NHA, SHA and the empanelled hospital, clause on patient acceptance.
 +  * **RTI Act 2005, Sections 6 and 7(1)**, including the **48-hour life-and-liberty proviso**.
 +  * **Article 21 of the Constitution**, right to health (per **Paschim Banga Khet Mazdoor Samity v State of West Bengal (1996)**).
 +  * **Clinical Establishments Act 2010** (where applicable).
 +
 +The CIC has held in **Anand Saxena v NHA (CIC, 2021)** and similar cases that pre-authorisation logs, package code mapping and empanelment records are disclosable to the patient.
 +
 +===== Step-by-step process =====
 +
 +  - **Identify the right PIO.** Three layers: (1) NHA, Indian Habitat Centre, New Delhi; (2) SHA of your state; (3) District Implementing Unit (usually under the Chief Medical Officer).
 +  - **Pin the visit.** PMJAY ID, hospital name and code, date and time of attendance, OPD card or token, package code if known, treating doctor.
 +  - **Use the body's own redressal first.** PMJAY helpline 14555 / 1800-111-565, SHA grievance portal, pmjay.gov.in grievance.
 +  - **Draft the RTI** asking for the empanelment status, the pre-auth trail, the denial noting, the SECC eligibility entry and the SHA grievance file.
 +  - **Mark life-and-liberty if applicable**, when treatment is being delayed for a serious condition, invoke the 48-hour proviso.
 +  - **Pay ₹10 fee** through online RTI or IPO.
 +  - **Wait 30 days** (or 48 hours).
 +
 +===== Format / template =====
 +
 +<code>
 +To,
 +The Public Information Officer,
 +[National Health Authority / State Health Agency / District Implementing Unit]
 +[Full address]
 +
 +Subject: RTI under Section 6 regarding denial of cashless treatment under PMJAY at [Hospital name and code], dated [DD/MM/YYYY]
 +
 +Sir / Madam,
 +
 +I, [Full name / patient relationship], a citizen of India and a PMJAY beneficiary holding card / family ID [number], request the following under the RTI Act 2005. Fee of Rs. 10 paid online / by IPO.
 +
 +In respect of the visit / admission of patient [Name] at [Hospital name and code] on [DD/MM/YYYY]:
 +
 +1. Whether the hospital is on the PMJAY empanelment list as on that date, with effective date of empanelment.
 +2. Package code(s) corresponding to the diagnosis / procedure noted on the OPD or IPD record.
 +3. Pre-authorisation log: requests filed, reasons for rejection or downgrade, and SHA approver's noting.
 +4. Denial endorsement on the OPD card / admission slip and the reason recorded in writing.
 +5. Whether any payment was demanded; if so, the receipt number.
 +6. SECC eligibility entry linking my name to PMJAY for the present family ID.
 +7. Standard Operating Procedure for cashless treatment under PMJAY at empanelled hospitals.
 +8. Status of any grievance filed by me against the hospital, including ticket number, present custodian and reasons recorded.
 +9. Penalty action, if any, taken against the hospital under the Tripartite Agreement.
 +
 +[If applicable: This is a life-and-liberty matter under the proviso to Section 7(1); reply is sought within 48 hours.]
 +
 +I invoke Section 10 (severability). I undertake to pay further fee under Section 7(3).
 +
 +Yours faithfully,
 +[Signature, name, date]
 +</code>
 +
 +===== Common mistakes =====
 +
 +  * **Filing only with the hospital.** Empanelled private hospitals are not directly RTI-amenable. Address NHA / SHA.
 +  * **Using the wrong card.** PMJAY family ID, e-card and Ayushman Bharat Health Account (ABHA) are different. Identify the right one.
 +  * **Forgetting the SECC link.** Many denials are due to "name not in beneficiary list". Ask for the SECC link and the grievance route under Additional Beneficiary mechanism.
 +  * **Asking for "package upgrade".** PIO cannot upgrade. Ask for the package code rule and the pre-auth approver's reasoning.
 +  * **Skipping helpline 14555.** Often resolves in hours; RTI is the backup.
 +
 +===== Appeal or next step =====
 +
 +  * **No reply in 30 days (or 48 hours)** → First Appeal under Section 19(1).
 +  * **PMJAY grievance escalation** → SHA appellate authority, then NHA grievance cell.
 +  * **Writ in High Court** under Article 21 for denial of life-saving treatment.
 +  * **Consumer complaint** for paid services after denial, if you paid out of pocket despite eligibility, you can seek refund through the SHA grievance cell or consumer commission.
 +
 +===== FAQs =====
 +
 +==== Can an empanelled hospital refuse a PMJAY beneficiary? ====
 +
 +No. The Tripartite Agreement and PMJAY Operational Guidelines require acceptance for the listed package. Refusal is grounds for action by SHA, including suspension and recovery of penalty.
 +
 +==== What if my name is not on the SECC list? ====
 +
 +Ask via RTI for the additional-beneficiary route notified by your state, and for the grievance file. Many states permit Antyodaya, BOCW and other identity proofs.
 +
 +==== Will RTI restart the treatment? ====
 +
 +No directly, but a parallel writ under Article 21, backed by the RTI denial endorsement, has worked in many High Courts.
 +
 +==== Is NHA a public authority? ====
 +
 +Yes, it is a registered society under DA&FW, financed entirely by the central government, with a designated CPIO.
 +
 +==== What records can a deceased patient's family ask for? ====
 +
 +The pre-auth trail, package code, denial endorsement, treatment records and bills. With death certificate and relationship proof.
 +
 +==== Are private hospitals public authorities? ====
 +
 +Generally no, unless substantially financed. But under PMJAY, their conduct is regulated through SHA, which is the public authority.
 +
 +==== Can I get the empanelment list of hospitals? ====
 +
 +Yes. NHA publishes it on pmjay.gov.in; if outdated, RTI to NHA / SHA gives the live list.
 +
 +===== Sources =====
 +
 +  * National Health Authority: [[https://nha.gov.in|nha.gov.in]]
 +  * PMJAY portal: [[https://pmjay.gov.in|pmjay.gov.in]]
 +  * Ministry of Health and Family Welfare: [[https://mohfw.gov.in|mohfw.gov.in]]
 +  * RTI Online: [[https://rtionline.gov.in|rtionline.gov.in]]
 +  * CPGRAMS: [[https://pgportal.gov.in|pgportal.gov.in]]
 +
 +Last reviewed: 9 May 2026.
 +
 +===== Related guides =====
 +
 +  * [[https://righttoinformation.wiki/tools/ai-rti-draft-app.html|AI RTI Drafter]]
 +  * [[guide|Guide hub]]
 +  * [[guide:applicant:application|How to file an RTI application]]
 +  * [[guide:applicant:government-hospital-records-rti|RTI for government hospital records]]
 +  * [[guide:applicant:rti-vs-complaint|RTI vs complaint]]
 +  * [[guide:applicant:ration-card-deletion-rti|RTI for ration card deletion]]
 +  * [[guide:applicant:first-appeal|First Appeal procedure]]
 +===== Ayushman Bharat denial RTI: How to challenge rejected claims and cards (2026) =====
 +
 +Ayushman Bharat denial — complete guide on challenging rejected Ayushman Bharat claims and cards through RTI:
 +
 +  - **Step 1: Common reasons for Ayushman Bharat denial.** (a) card-related: (i) name mismatch — between the Aadhaar — and the Ayushman card, (ii) family not in the SECC 2011 database — or the eligible list, (iii) ration card number — not linked — or not matching, (iv) mobile number — not linked — or not verified, (b) claim-related: (i) pre-existing condition — not covered — or excluded, (ii) the treatment — is not in the approved package list — HBP (Health Benefits Package), (iii) the hospital — is not empanelled — or the empanelment — was cancelled, (iv) the claim — was not submitted — within the time limit — 48 hours for pre-auth — and 7 days for the final claim, (v) the documents — are incomplete — or mismatched, (c) hospital-related: (i) the hospital — refuses to treat — under Ayushman — despite being empanelled, (ii) the hospital — demands money — despite the Ayushman card, (iii) the hospital — refers the patient — to another hospital — without justification.
 +  - **Step 2: Steps to challenge Ayushman Bharat denial.** (a) Step 1 — get the reason in writing: ask the hospital — and the Ayushman Mitra — to provide the reason — for the denial — in writing, (b) Step 2 — file a complaint: file a complaint — with: (i) the hospital — to the Medical Superintendent, (ii) the SHA (State Health Authority) — on the toll-free number 14555 — or the Ayushman portal, (iii) the NHA (National Health Authority) — on the Ayushman portal — or the grievance portal, (c) Step 3 — escalate: if the complaint — is not resolved — within 15 days — escalate to: (i) the District Magistrate (DM), (ii) the Chief Minister's helpline, (iii) the Insurance Ombudsman — if the insurance company — is involved, (d) Step 4 — file RTI: file RTI — with the NHA — or the SHA — to get: (i) the card status, (ii) the claim status, (iii) the denial reason, (iv) the grievance status.
 +  - **Step 3: File RTI on Ayushman Bharat denial.** File RTI with the National Health Authority (NHA) or the State Health Authority (SHA) asking for: (a) the card: "Provide the status — of the Ayushman Bharat card — for [name], [ration card number], [Aadhaar number] — including: (i) the application date, (ii) the approval date, (iii) the rejection date — and reason — if rejected, (iv) the card number — if issued", (b) the claim: "Provide the status — of the Ayushman Bharat claim — for [patient name], [hospital name], [claim number] — including: (i) the date of submission, (ii) the date of processing, (iii) the approved amount, (iv) the rejected amount — and reason — if rejected, (v) the payment date — and the amount — if paid", (c) the grievance: "Provide the status — of the grievance — filed on [date] — reference number [number] — including: (i) the complaint details, (ii) the action taken, (iii) the resolution, (iv) the date of resolution", (d) the hospital: "Provide the empanelment status — of [hospital name] — including: (i) the date of empanelment, (ii) the specialties covered, (iii) the cancellation — if any — and the reason, (iv) the complaints — against the hospital — and the action taken", (e) the package: "Provide the approved package list — HBP — for [treatment name] — including: (i) the package code, (ii) the package amount, (iii) the inclusions, (iv) the exclusions".
 +  - **Step 4: The National Health Authority (NHA) as a public authority.** (a) the NHA — is a public authority — under the RTI Act — and the CPIO — is the PIO — for the central-level queries, (b) the SHA — is the PIO — for the state-level queries — and the State Information Commission — hears the second appeals, (c) the NHA — has designated: (i) the CPIO — at the headquarters — in New Delhi, (ii) the APIOs — at the regional offices, (d) the RTI application — can be filed: (i) online — on the NHA website — nha.gov.in, (ii) by post — to the CPIO, NHA, New Delhi, (iii) in person — at the NHA office.
 +  - **Step 5: Key legal provisions.** (a) the Ayushman Bharat PMJAY — is a scheme — under the Ministry of Health and Family Welfare — and the NHA — implements the scheme, (b) the PMJAY — provides: (i) Rs 5 lakh — per family per year — for the secondary and tertiary care, (ii) cashless treatment — at the empanelled hospitals, (iii) no cap on the family size — and the age, (c) the denial — of the treatment — by an empanelled hospital — is a violation — of the PMJAY guidelines — and the patient can complain — to the SHA — and the NHA, (d) the Supreme Court — and the High Courts — have held — that the denial — of the medical treatment — under a government scheme — is a violation — of the right to life — under Article 21 — and the patient can approach — the court — for the treatment.
 +  - **Step 6: Sample RTI application for Ayushman denial.** "To, the CPIO, National Health Authority, New Delhi. Subject: Application under RTI Act, 2005 — for Ayushman Bharat card and claim status. Sir, I request the following information — under Section 6(1) of the RTI Act, 2005: (i) Provide the status — of the Ayushman Bharat card — for [name], [ration card number], [Aadhaar number], (ii) Provide the reason — for the rejection — of the card — if rejected, (iii) Provide the status — of the claim — for [patient name], [hospital name], [claim number], (iv) Provide the reason — for the rejection — of the claim — if rejected, (v) Provide the grievance status — for the complaint — filed on [date]. I am paying the application fee of Rs 10 — by IPO. Yours faithfully, [Name, Address]."
 +  - **Step 7: Practical tips.** (a) keep all documents (keep the Ayushman card — the Aadhaar — the ration card — the hospital bills — the discharge summary — and the claim documents — safely), (b) file the complaint promptly (file the complaint — within 15 days — of the denial — to avoid the time bar), (c) cite the PMJAY guidelines (if the hospital denies — cite the PMJAY guidelines — which require the empanelled hospital — to treat — without demanding money), (d) file RTI (if the complaint — is not resolved — file RTI — to get the status — and the reason — and to build the case), (e) approach the court (if the RTI — and the complaint — do not resolve — approach the High Court — for the treatment — and the compensation), (f) Example: A patient — was denied treatment — by an empanelled hospital — who demanded Rs 50,000 — the patient filed a complaint — with the SHA — and RTI — with the NHA — the RTI reply showed — that the hospital — was empanelled — and the treatment — was in the HBP — the patient filed a writ — in the High Court — the court directed the hospital — to treat — without money — and the NHA — to take action — against the hospital.
 +
 +See [[https://righttoinformation.wiki/guide/applicant/ayushman-bharat-denial-rti|Ayushman Denial RTI]] and [[https://righttoinformation.wiki/apply-ayushman-bharat-abha-card-2026|Ayushman Card 2026]].
 +
 +{{tag>ayushman bharat denial rti pmjay claim rejection card status nha sha grievance hospital empanelment hbp 2026}}