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| + | metatag-title=PMJAY Claim Rejected? CGRMS Grievance and RTI Guide | ||
| + | metatag-description=(CGRMS at cgrms.nha.gov.in is the PM-JAY grievance portal. Lodge and track a complaint by UGN, call 14555, escalate hospital to SHA to NHA, and use RTI.)& | ||
| + | metatag-keywords=(PMJAY claim rejected, cgrms.nha.gov.in, | ||
| + | metatag-robots=(index, | ||
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| + | ====== PMJAY claim rejected: file on CGRMS, escalate, then use RTI ====== | ||
| + | |||
| + | {{ : | ||
| + | |||
| + | <WRAP center round info 95%> | ||
| + | **Quick Reply:** The PM-JAY grievance portal is CGRMS at cgrms.nha.gov.in - it is live, and the National Health Authority' | ||
| + | </ | ||
| + | |||
| + | **Reviewed on:** 2026-08-27. | ||
| + | |||
| + | ===== The grievance portal: CGRMS, live and official ===== | ||
| + | |||
| + | cgrms.nha.gov.in is the Centralized Grievance Redressal Management System, CGRMS, run by the National Health Authority for Ayushman Bharat PM-JAY, and it was verified live and reachable while this guide was written. The NHA's own website navigation lists it as the " | ||
| + | |||
| + | The portal states its own scope plainly, and these four lines come straight from its screens: a grievance "can be lodged by any stakeholder for AB PM-JAY and Convergence schemes"; | ||
| + | |||
| + | One number to carry before anything else: **14555**, the toll-free PM-JAY helpline. It is printed on the NHA website, in the CGRMS portal itself, and in both the Parliament reply and the ministry' | ||
| + | |||
| + | ===== Filing on CGRMS: the real form flow ===== | ||
| + | |||
| + | The portal works on an OTP, so keep the mobile phone handy before you start. The flow below is the one the portal actually presents, field by field. | ||
| + | |||
| + | - **Register the grievance.** Choose who you are filing as - the portal calls this the applicant type - and confirm the scheme: it asks whether you are raising the grievance under PM-JAY, and otherwise lets you pick the scheme. You then enter your Scheme ID or Ayushman Card ID. | ||
| + | - **Pick the grievance type and sub-type.** The portal asks for a Grievance Type and a Grievance Sub Type - the nature of the grievance. " | ||
| + | - **Identify the hospital.** You enter the hospital name or ID, its type, and the state and district of both the beneficiary and the hospital. The portal also asks whether the patient is currently in hospital - answer this truthfully, because an in-hospital grievance moves on a faster clock. | ||
| + | - **Describe and upload.** Write the grievance description. You can attach supporting documents in PDF, JPEG or PNG up to 10 MB each, and the portal also accepts audio and video evidence - MP3, MP4, MOV, AVI, MPEG, MPG or AMR - within the same 10 MB limit. Attach the denial slip, the bills if you were forced to pay, and the prescription. | ||
| + | - **Declare and verify.** Tick the declaration that the facts stated are true to the best of your knowledge, and enter the OTP sent to your mobile number. | ||
| + | - **Save the UGN.** The portal generates a Unique Grievance Number - the screen calls it your UGN for future reference. Write it down exactly. This one number is your handle for tracking, appeals and any RTI later. | ||
| + | |||
| + | If you cannot use the portal, the guideline allows the same grievance by other routes: the call centre at 14555 (call-centre executives register the details in CGRMS themselves and forward them to the district nodal officer), a letter, telephone call, e-mail or fax to the State Health Agency or the NHA, or directly to the District Grievance Nodal Officer, who must enter offline grievances into the portal. | ||
| + | |||
| + | ===== Tracking your grievance: the UGN and what the statuses mean ===== | ||
| + | |||
| + | Go back to cgrms.nha.gov.in, | ||
| + | |||
| + | Give feedback when the case closes: the portal has a feedback step, and your answer is part of the record the committees review. | ||
| + | |||
| + | ===== What claim rejected usually means ===== | ||
| + | |||
| + | Hospitals rarely say "claim rejected" | ||
| + | |||
| + | - **"Not in the package." | ||
| + | - **" | ||
| + | - **"The insurance company rejected the claim." | ||
| + | - **" | ||
| + | - **"We are not empanelled for this." | ||
| + | |||
| + | One rejection reason you can firmly cross off: **pre-existing disease**. The ministry' | ||
| + | |||
| + | ===== Escalation: hospital to State Health Agency to NHA ===== | ||
| + | |||
| + | The escalation is not an informal appeal to whoever will listen. The NHA's Grievance Redressal Guidelines define the ladder, and the February 2025 Parliament reply confirms a three-tier system - District, State and National - with a dedicated nodal officer and Grievance Redressal Committee at each tier. | ||
| + | |||
| + | ^ Your situation ^ First authority ^ Time limit ^ If it is not resolved ^ | ||
| + | | Denial or cash demand while the patient is still in hospital | District Grievance Nodal Officer, DGNO | 48 hours | Referred to the District Grievance Redressal Committee | | ||
| + | | Denial or cash demand raised at or after discharge | DGNO | 15 days | DGRC decides within 30 days of the DGNO decision | | ||
| + | | Either side unhappy with the DGNO order | Appeal to DGRC | within 30 days of the order | DGRC has 30 days to resolve | | ||
| + | | Either side unhappy with the DGRC decision | Appeal to SGRC | within 30 days | SGRC has 30 days to resolve | | ||
| + | | Either side unhappy with the SGRC order | NGRC | within 30 days of the order | NGRC decides within 30 days; its decision is final | | ||
| + | |||
| + | Who chairs these committees is fixed by the guideline: the District Grievance Redressal Committee is chaired by the Head of the District - the District Magistrate, District Collector or Deputy Commissioner; | ||
| + | |||
| + | And the system has teeth against hospitals, not just patients: the Parliament reply records that State Health Authorities can act against errant hospitals by de-empanelling them, levying penalties, suspending them, issuing warning letters, and lodging FIRs. | ||
| + | |||
| + | ===== Helplines and other channels ===== | ||
| + | |||
| + | - **14555** - the toll-free national PM-JAY helpline, verbatim on the NHA site, inside the CGRMS portal, and in the ministry' | ||
| + | - **1800110770** - a missed-call line the ministry gives specifically for information on the Vay Vandana senior-citizen card. | ||
| + | - **CPGRAMS at pgportal.gov.in** - the central government grievance portal, a useful parallel route with its own appeal step, which reaches the right ministry department. | ||
| + | - **Letter, e-mail or fax to the State Health Agency or the NHA** - the guideline' | ||
| + | - **The hospital help desk.** Every empanelled hospital must mandatorily run a help desk - the Arogya Mitra Sahayta Kendra, staffed by the Pradhan Mantri Arogya Mitra - to help beneficiaries complete formalities, | ||
| + | |||
| + | ===== What PM-JAY is ===== | ||
| + | |||
| + | Ayushman Bharat PM-JAY, launched on 23 September 2018 at Ranchi, gives eligible families cashless and paperless cover of up to Rs 5 lakh per family per year for secondary and tertiary care hospitalisation at empanelled hospitals. It is the world' | ||
| + | |||
| + | ===== Legal position in India ===== | ||
| + | |||
| + | There is no PMJAY Act. PM-JAY is a centrally sponsored scheme run on guidelines issued by the National Health Authority, which is an attached office of the Ministry of Health and Family Welfare. The grievance timelines and committees described above come from those binding guidelines, not from statute. | ||
| + | |||
| + | What is enforceable at the hospital counter is the empanelment itself: under the terms and conditions of empanelment, | ||
| + | |||
| + | Because the NHA and the State Health Agencies are public authorities, | ||
| + | |||
| + | ===== Step-by-step when care is denied ===== | ||
| + | |||
| + | - **Ask for the denial in writing at the help desk.** Note the date, time and the staff name. A verbal "not covered" | ||
| + | - **Call 14555 from the hospital itself.** Give the hospital name, your card number and the exact refusal. The call centre registers the grievance in CGRMS; note the complaint or UGN reference. | ||
| + | - **Lodge on CGRMS the same day.** Follow the form flow above, choose the sub-type that matches your case, and answer the still-in-hospital question honestly - that answer puts a 48-hour clock on the district nodal officer. | ||
| + | - **Do not pay quietly if you can avoid it.** A covered package is meant to be cashless. If you are forced to pay, keep every bill, receipt and discharge summary - they are both the grievance evidence and the refund claim. | ||
| + | - **Watch the clock, then escalate.** In-hospital and 48 hours pass, or after discharge 15 days pass: the case should move to the District Committee. Use the UGN to track, and quote it in every escalation. Appeal windows at each rung are 30 days. | ||
| + | - **File an RTI for the paper trail.** The sample letter below asks for the recorded rejection reason, the hospital' | ||
| + | - **Use CPGRAMS in parallel if you prefer** - pgportal.gov.in, | ||
| + | |||
| + | ===== Documents required ===== | ||
| + | |||
| + | * Ayushman Bharat or Vay Vandana card number and a copy of the card | ||
| + | * Beneficiary ID and a photo ID such as Aadhaar | ||
| + | * Name, address and hospital ID of the empanelled hospital | ||
| + | * The written denial slip, or a dated note of the verbal refusal with the staff name | ||
| + | * All bills and payment receipts if you were made to pay | ||
| + | * Doctor' | ||
| + | * The UGN or the 14555 complaint number | ||
| + | * Documents and any audio or video evidence, each within 10 MB, ready to upload | ||
| + | |||
| + | ===== Common mistakes ===== | ||
| + | |||
| + | * **Waiting for the hospital to change its mind.** The 48-hour clock runs from registration while the patient is in hospital. Register on CGRMS or through 14555 the same day. | ||
| + | * **Losing the UGN.** Without the Unique Grievance Number you cannot track, appeal, or anchor an RTI. Save it the moment the portal issues it. | ||
| + | * **Accepting a verbal not covered.** Make the desk write it, or write it yourself with date, time and name. | ||
| + | * **Paying cash silently.** For a covered package that is exactly what the system penalises hospitals for - but only if your bills and grievance exist. | ||
| + | * **Believing the pre-existing disease excuse.** The ministry' | ||
| + | * **Skipping RTI.** The recorded reason for rejection sits in a file the SHA holds. Section 6(1) puts it in your hands for Rs 10. | ||
| + | |||
| + | <WRAP center round box> | ||
| + | **An illustrative worked example - a heart procedure flagged as not in the package.** | ||
| + | |||
| + | The details follow the documented process end to end; the name is illustrative, | ||
| + | |||
| + | A family in Bihar took their father to an empanelled private hospital with the Ayushman card. The desk said his heart procedure was "not in the package" | ||
| + | </ | ||
| + | |||
| + | ===== Sample RTI letter to the State Health Agency ===== | ||
| + | |||
| + | < | ||
| + | To, | ||
| + | The Central Public Information Officer, | ||
| + | State Health Agency / National Health Authority, | ||
| + | [full office address] | ||
| + | |||
| + | Subject: Request for information under the RTI Act 2005 - PM-JAY | ||
| + | claim rejection and grievance number [UGN] | ||
| + | |||
| + | 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: ____________ | ||
| + | Grievance number (UGN): ____________ | ||
| + | |||
| + | 1. The recorded reason for rejecting cashless treatment or the claim | ||
| + | in my case, with copies of the relevant file notings. | ||
| + | 2. Whether the above hospital is currently empanelled under PM-JAY, | ||
| + | with the date and validity period of its empanelment. | ||
| + | 3. Whether the procedure or package in my case is covered under | ||
| + | | ||
| + | 4. The action taken on my grievance number (UGN) registered on CGRMS, | ||
| + | its current status, and the officer responsible. | ||
| + | 5. Whether any penalty, warning or action has been taken against the | ||
| + | | ||
| + | |||
| + | 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 Rs 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, move a first appeal - build it with the [[https:// | ||
| + | |||
| + | ===== Frequently asked questions ===== | ||
| + | |||
| + | ==== What is the CGRMS portal URL for PM-JAY complaints? ==== | ||
| + | |||
| + | cgrms.nha.gov.in - the Centralized Grievance Redressal Management System of the National Health Authority, verified live at the time of writing and linked as the Grievance Portal from the NHA website. The older address in the NHA guideline, cgrms.pmjay.gov.in, | ||
| + | |||
| + | ==== How do I check my Ayushman grievance status? ==== | ||
| + | |||
| + | Open the CGRMS portal, choose Track Status, and enter your Unique Grievance Number, the UGN the portal issued when you filed. The status shows as Pending, Queried, Received/ | ||
| + | |||
| + | ==== What is the PM-JAY helpline number? ==== | ||
| + | |||
| + | 14555, toll free. It appears on the NHA website, inside the CGRMS portal, and in the Ministry of Health statements to Parliament. State call centres also take PM-JAY grievances and register them in CGRMS. For the Vay Vandana senior-citizen card specifically, | ||
| + | |||
| + | ==== The hospital says the treatment is not in the package. Can it refuse? ==== | ||
| + | |||
| + | Only if the procedure genuinely is outside the package list - the ministry describes around 2,000 covered procedures at fixed package rates. Ask the help desk to state the rejection in writing with the package lookup, lodge a Denied Treatment grievance on CGRMS while the patient is admitted, and if needed use RTI to get the recorded reason and the package position. A covered procedure refused for cash is exactly what the grievance committees and the State Health Agency' | ||
| + | |||
| + | ==== Can an empanelled hospital ask me to pay cash? ==== | ||
| + | |||
| + | Not for a covered package. Under the terms of empanelment, | ||
| + | |||
| + | ==== How long does a PM-JAY grievance take? ==== | ||
| + | |||
| + | While the patient is in hospital: the District Grievance Nodal Officer is to resolve it within 48 hours, failing which it goes to the District Committee. For grievances raised at or after discharge: the DGNO has 15 days, the District Committee 30 days after that. Appeals at each level are within 30 days, and each committee - District, State, then National - has 30 days to decide, with the National committee' | ||
| + | |||
| + | ==== Is there a PMJAY Act I can quote? ==== | ||
| + | |||
| + | No. PM-JAY is a centrally sponsored scheme run by the National Health Authority on government guidelines, not an Act of Parliament. The timelines and committees come from the NHA Grievance Redressal Guidelines. The Act you can quote against the NHA or a State Health Agency is the RTI Act 2005, because both are public authorities. | ||
| + | |||
| + | ==== Does the Rs 5 lakh cover include senior citizens? ==== | ||
| + | |||
| + | Yes. Since 29 October 2024, every senior citizen aged 70 and above gets Rs 5 lakh a year through the Ayushman Vay Vandana card, irrespective of socio-economic status - an additional top-up for families already covered. Senior citizens already covered by CGHS, ECHS or similar schemes choose one scheme or the other. Register at an empanelled hospital, on the Ayushman app, or at beneficiary.nha.gov.in. | ||
| + | |||
| + | ==== Does PM-JAY exclude pre-existing diseases? ==== | ||
| + | |||
| + | No. The Ministry of Health and Family Welfare states the cover applies to all pre-existing diseases from the first day, without any waiting period. If a hospital cites your medical history as the reason, that is not a scheme ground - record it and grievance it. | ||
| + | |||
| + | ==== How does RTI help with a rejected claim? ==== | ||
| + | |||
| + | The recorded reason for the rejection, the hospital' | ||
| + | |||
| + | ==== What if I already paid the hospital? ==== | ||
| + | |||
| + | Keep every bill and receipt, and say so in the grievance: demanding money for a covered package is a recognised grievance category both before and after discharge. Track the case by UGN, and if the reply claims the package was uncovered, use RTI to get the package position in writing - that answer is the basis for demanding the refund. | ||
| + | |||
| + | ==== How do I check PM-JAY eligibility? | ||
| + | |||
| + | On the NHA beneficiary portal at beneficiary.nha.gov.in - the Am I Eligible service - or through the Ayushman app, or at any empanelled hospital' | ||
| + | |||
| + | ==== What if nothing works even after the National committee? ==== | ||
| + | |||
| + | You still hold two general legal routes: a consumer complaint for deficiency of service against the hospital, and a writ petition to the High Court under Article 226 against an authority that fails to act. Both are last resorts after the grievance ladder and your RTI record - and both are stronger with the UGN trail and the RTI replies attached. | ||
| + | |||
| + | ===== Sources ===== | ||
| + | |||
| + | * **National Health Authority, Grievance Portal (CGRMS)** - https:// | ||
| + | * **NHA website (About, Am I Eligible, helpline 14555)** - https:// | ||
| + | * **NHA beneficiary portal (Am I Eligible, Vay Vandana self-registration)** - https:// | ||
| + | * **NHA Guidelines for Grievance Redressal (committees, | ||
| + | * **NHA Guidelines for Ayushman Mitra (mandatory hospital help desk)** - https:// | ||
| + | * **PIB, MoHFW, 4 February 2025 - three-tier grievance system, CGRMS and 14,555 call centres, action against errant hospitals** - https:// | ||
| + | * **PIB, MoHFW, 9 December 2024 - Vay Vandana launch 29 October 2024, Rs 5 lakh for all senior citizens 70+, pre-existing diseases covered from day one, 14555 and 1800110770** - https:// | ||
| + | * **PIB, MoHFW, 22 September 2018 - PM-JAY launch at Ranchi, Rs 5 lakh per family per year, cashless and paperless** - https:// | ||
| + | * **CPGRAMS central grievance portal** - https:// | ||
| + | * **Right to Information Act 2005** - https:// | ||
| + | |||
| + | ===== Related on RTI Wiki ===== | ||
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