PMJAY Claim Rejected Grievance - citizen guide 2026

Your father is admitted, you carried the Ayushman card, and the hospital desk says the treatment is “not covered” or asks for cash. You can fight this. First call the PM-JAY helpline 14555, then lodge a grievance on the CGRMS portal, and escalate to the State Health Agency if needed.

Short on time? Read the step-by-step section and use the sample RTI letter below.

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, called PM-JAY, is a government health scheme. It gives eligible families cashless cover of up to ₹5 lakh per family per year for secondary and tertiary hospital care at empanelled hospitals. It was launched on 23 September 2018 and is run by the National Health Authority.

PM-JAY is a centrally sponsored scheme, not an Act of Parliament. There is no “PMJAY Act”. It runs on the scheme guidelines and grievance rules issued by the National Health Authority (NHA), which is an attached office of the Ministry of Health and Family Welfare set up by government notification.

Treatment under PM-JAY is meant to be cashless and paperless at empanelled hospitals. An empanelled hospital should not ask a beneficiary for money for a covered package. If it does, that is a violation you can report.

In 2024 the scheme was widened. The Ayushman Vay Vandana Card was launched on 29 October 2024 to give ₹5 lakh annual cover to all senior citizens aged 70 and above, with no income test.

The NHA runs a three-tier grievance system. Committees sit at District, State and National levels, chaired by the District Magistrate, the State Health Agency CEO and the NHA CEO. Each level has a Grievance Nodal Officer.

Because the NHA and the State Health Agencies are public authorities, the Right to Information Act 2005 applies to them. You can file an RTI under Section 6 to get the written reason for a rejection or a hospital's empanelment status. See the full RTI Act 2005.

1. Ask for the reason in writing. At the hospital, ask the Ayushman Mitra or PM-JAY desk to put the denial in writing. Note the date, time and the staff name.
2. Call 14555 from the hospital. The toll-free PM-JAY helpline is 14555 or 1800-111-565. Tell them the hospital name, your card number and that cashless care is being refused. Note the complaint number they give you.
3. Do not pay quietly if you can avoid it. A covered package should be cashless. If you are forced to pay, keep every bill and receipt. You will need them to claim a refund.
4. Lodge a written grievance on CGRMS. Go to the Central Grievance Redressal Management System portal at cgrms.nha.gov.in. Register the grievance with your card details, the hospital name and what happened. Save the grievance ID.
5. Wait for the timeline. The committee should reach a decision within 30 days. If the grievance is not resolved in 15 days, it is referred up to the District Grievance Redressal Committee and then the State level.
6. Escalate to the State Health Agency. If the District level does not help, the State Grievance Nodal Officer and the State Health Agency CEO chair the next tier. The NHA sits at the top.
7. File an RTI for the paper trail. Ask the State Health Agency or NHA, in writing, for the recorded reason for the rejection and the hospital's empanelment status. This often unlocks a stuck case.
8. Use CPGRAMS as a parallel route. You can also file on the central government grievance portal CPGRAMS at pgportal.gov.in, which routes to the right ministry and has an appeal option.

• Ayushman Bharat or Vay Vandana card number and a copy of the card
• Beneficiary ID and a photo ID such as Aadhaar
• Name and address of the empanelled hospital
• The written denial slip or any message refusing cashless care
• All bills and payment receipts if you were made to pay
• Doctor's notes, admission papers and the treatment or package name
• Any complaint or grievance number from 14555 or CGRMS

• Paying cash without a fight. A covered package is cashless. Call 14555 before you pay so the refusal is on record.
• No written denial. A verbal “not covered” is hard to challenge. Ask for it in writing or note the staff name and time.
• Missing the grievance ID. Without the CGRMS grievance ID or the 14555 complaint number, you cannot track or escalate.
• Going only to the hospital. The hospital that refused you will not police itself. Use the NHA grievance channels.
• Skipping RTI. Under Section 6 of the RTI Act 2005 you can demand the written reason for a rejection. Many people never ask.

To,
The Public Information Officer (CPIO),
State Health Agency / National Health Authority,
[full office address]

Subject: Request for information under the RTI Act 2005 - PM-JAY claim rejection

Sir/Madam,

Under Section 6(1) of the Right to Information Act 2005, I request
the following information regarding my Ayushman Bharat PM-JAY case.

My card number: ____________
Hospital name and address: ____________
Date of admission / denial: ____________

1. The recorded reason for rejecting cashless treatment / the claim
   in my case, with copies of the relevant file notings.
2. Whether the above hospital is currently empanelled under PM-JAY,
   and the date and validity of its empanelment.
3. Whether the procedure / package in my case is covered under
   PM-JAY, with the package code and rate.
4. Action taken on my grievance number ________ filed on CGRMS,
   with current status and the responsible officer.

If any part is held by another authority, please transfer it under
Section 6(3) and inform me. I request the reply within the time
fixed under Section 7(1). I am eligible for a fee waiver if I am
below the poverty line and enclose proof; otherwise I enclose the
₹10 application fee.

If the reply is not received in time, I reserve my right of first
appeal under Section 19(1).

Place:
Date:
Signature:
Name and full address:

If the office gives no reply or an evasive one, you can move a first appeal. Build it with the First Appeal Builder. To draft a fresh RTI fast, try the AI RTI Drafter. If typing is hard, use AwaazRTI voice tool.

No. PM-JAY is a centrally sponsored scheme run by the National Health Authority, not an Act of Parliament. It works on scheme guidelines and grievance rules. The Act you can quote against the NHA or a State Health Agency is the RTI Act 2005, because both are public authorities.

No, not for a covered package. PM-JAY is meant to be cashless and paperless at empanelled hospitals. If a hospital demands money for a covered treatment, call 14555 at once and lodge a CGRMS grievance. Keep every receipt so you can claim a refund.

The national toll-free helpline is 14555. The number 1800-111-565 is also used by the National Call Centre and is linked to the grievance portal. Call before you pay so the refusal is recorded.

On the Central Grievance Redressal Management System (CGRMS) portal at cgrms.nha.gov.in. Register with your card number, the hospital name and what happened. Save the grievance ID. You can also use the central CPGRAMS portal at pgportal.gov.in.

The committee should decide within 30 days. If your grievance is not resolved within 15 days, it is referred up to the District Grievance Redressal Committee, then the State and National committees chaired by the State Health Agency CEO and the NHA CEO.

Yes. Eligible families get up to ₹5 lakh per family per year. Since the Ayushman Vay Vandana Card launched on 29 October 2024, all senior citizens aged 70 and above also get ₹5 lakh annual cover, with no income test.

File an RTI under Section 6 of the RTI Act 2005 to the State Health Agency or NHA. Ask for the recorded reason for the rejection, the hospital's empanelment status, and whether your package is covered. A written reply often forces a stuck or wrong rejection to be corrected.

Keep all bills and receipts. Lodge the grievance on CGRMS and note that you were made to pay for a covered package. Ask, by RTI if needed, whether the package was covered. If it was, push for a refund through the grievance committee.

• National Health Authority, About PM-JAY - https://nha.gov.in/PM-JAY
• PM-JAY official portal - https://pmjay.gov.in
• CGRMS grievance portal - https://cgrms.nha.gov.in
• NHA Grievance Redressal Guideline OM, December 2021 - https://nha.gov.in
• Ayushman Vay Vandana Card for senior citizens 70+ launched 29 October 2024 - https://nha.gov.in
• CPGRAMS central grievance portal - https://pgportal.gov.in
• Right to Information Act 2005 - https://righttoinformation.wiki/act

• RTI Act 2005 full text and sections
• Draft your RTI with the AI RTI Drafter
• File a first appeal when the PIO does not reply
• AwaazRTI voice tool to file by speaking
• The RTI Playbook