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—rti-for-ayushman-bharat-claim [2026/07/04 00:41] (current) – created - external edit 127.0.0.1
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 +{{htmlmetatags>metatag-title=(Ayushman Bharat claim denied — RTI fix - RTI Wiki)&metatag-description=(Your Ayushman Bharat PMJAY claim was denied or stuck. File RTI to the State Health Agency or NHA for claim status, denial reasons and release dates in 30 days.)&metatag-keywords=(Ayushman Bharat RTI, PMJAY RTI, SHA, NHA, SECC 2011, health scheme RTI, claim denial)&metatag-robots=(index,follow)&metatag-og:title=(Ayushman Bharat claim denied — RTI fix - RTI Wiki)&metatag-og:description=(Your Ayushman Bharat PMJAY claim was denied or stuck. File RTI to the State Health Agency or NHA for claim status, denial reasons and release dates in 30 days.)&metatag-og:type=(article)}}
  
 +====== Ayushman Bharat claim denied — RTI fix ======
 +
 +{{:social:auto:rti-for-ayushman-bharat-claim.png?direct&1200 |Ayushman Bharat claim denied — RTI fix — RTI Wiki}}
 +
 +Ramesh took his mother to a empanelled hospital for a heart surgery. The hospital said the treatment was covered under Ayushman Bharat PMJAY, up to Rs.5 lakh per family per year. After the surgery, the hospital told him the claim was "pending" with the State Health Agency. Weeks passed. No one gave him a clear answer. The hospital blamed the state office, the state office blamed the central portal, and Ramesh was left running from desk to desk with a stack of papers.
 +
 +This is a story thousands of families recognise. A cashless health scheme that suddenly stops being cashless. The good news: you have a legal tool that forces a written reply. This page shows you, step by step, how to use a Right to Information application to get your PMJAY claim status, denial reasons, and a real timeline.
 +
 +<WRAP info>**Direct answer.** File an RTI to your **State Health Agency (SHA)** for claim and pre-auth records, and to the **National Health Authority (NHA)** for eligibility and scheme-level records. Ask five things: your eligibility status, the hospital pre-authorisation records, the claim status, the reason for any denial, and the projected release date. The authority must reply within **30 days**.</WRAP>
 +
 +===== What is Ayushman Bharat PMJAY =====
 +
 +Ayushman Bharat PMJAY gives families cashless hospital cover of up to **Rs.5 lakh per family per year** for secondary and tertiary care. The scheme is run by the **National Health Authority (NHA)** at the centre and by **State Health Agencies (SHA)** in each state.
 +
 +The NHA was reconstituted on **2 January 2019** as an attached office of the Ministry of Health and Family Welfare, by a Gazette Notification. It has full functional autonomy. Because it is a body created by a Central Government notification, the NHA is a **public authority** under section 2(h)(d) of the RTI Act 2005. That means it must designate Public Information Officers and make proactive disclosure under section 4(1)(b).
 +
 +In September 2024, the Union Cabinet extended PMJAY cover to **all senior citizens aged 70 and above**, regardless of income, with a separate **Ayushman Vay Vandana Card**. So the beneficiary base is wider than before, and more families now have a right to ask questions when a claim goes wrong.
 +
 +You can check your own eligibility and download your Ayushman card on the official NHA portal **beneficiary.nha.gov.in**. You log in with your registered mobile number and an OTP, then search by Aadhaar, or by Name plus Father's Name plus State, or by Ration Card. The primary database that decides eligibility is **SECC 2011** (the Socio-Economic Caste Census). If you want to confirm whether your state has added a top-up scheme on top of the central cover, see [[scheme-state:ayushman-bharat:start|your state's PMJAY scheme details]].
 +
 +===== Why an RTI works for a stuck claim =====
 +
 +A stuck PMJAY claim is not really a mystery. Somewhere in the chain there is a paper record: the pre-authorisation approval, the claim submission, the denial note, the audit flag, the release note. The hospital will not show you these files. The SHA call centre will not mail them to you. But under the RTI Act, a public authority must give a citizen copies of these records on request.
 +
 +That is the core idea. The SHA and NHA hold the records. They are public authorities. So you file an RTI, pay a Rs.10 fee, and the law forces a written reply within 30 days. You stop chasing desks and start holding paper.
 +
 +===== Step 1: Check your status first =====
 +
 +Before you file the RTI, gather the facts. Go to [[check-status:ayushman-bharat-status|check your Ayushman Bharat status]] on the beneficiary portal and note down your PMJAY beneficiary ID, the hospital name, the date of admission, the pre-authorisation number if you have it, and the claim reference number. Call the all-India toll-free PMJAY helpline **14555** (available 24 hours) and note the complaint number they give you. Also file a grievance on the CGRMS portal **cgrms.pmjay.gov.in**. The NHA Grievance Redressal Guidelines were issued in December 2021, so there is a defined grievance path you should trigger in parallel.
 +
 +These facts go into your RTI application. The more precise your numbers, the harder it is for the authority to give you a vague reply.
 +
 +===== Step 2: Decide where to file =====
 +
 +This is where most people go wrong. PMJAY runs on two levels:
 +
 +  - **State Health Agency (SHA)** — runs the claim pipeline in your state, handles pre-authorisation, hospital empanelment at state level, and claim settlement. File here for your **claim status, pre-auth records, denial reasons, and payment release**.
 +  - **National Health Authority (NHA)** — runs the central portal, the beneficiary database, and the scheme rules. File here for your **eligibility status, SECC linkage, and scheme-level policy records**.
 +
 +File at **both** if your problem crosses both levels. Filing only at the hospital is the single biggest mistake people make. The hospital is a service provider, not the public authority that holds the records you need.
 +
 +===== Step 3: The five questions to ask =====
 +
 +Ask exactly these five things. They are designed to cover the whole chain from eligibility to payment:
 +
 +  - **Eligibility status:** Is my family eligible under PMJAY, and on what SECC 2011 basis? Give your beneficiary ID.
 +  - **Pre-authorisation records:** Copy of the pre-auth approval, the package code, and the approved amount for my hospitalisation on the given date.
 +  - **Claim status:** Current status of my claim reference number, and the date it entered each stage of the pipeline.
 +  - **Denial reasons:** If denied or pending, the exact recorded reason, the section of the scheme guideline or package rule it relies on, and the officer who recorded it.
 +  - **Projected release:** The expected date of payment to the hospital, or the date my claim will move to the next stage.
 +
 +===== Step 4: Use the template =====
 +
 +<code>
 +To: The Public Information Officer,
 +    State Health Authority / National Health Authority
 +    [full address]
 +
 +Subject: Application under section 6 of the RTI Act 2005 —
 +        PMJAY claim status
 +
 +1. My name: [full name]
 +2. PMJAY beneficiary ID: [ID]
 +3. Hospital: [name, city]
 +4. Date of admission: [date]
 +5. Pre-authorisation number: [if known]
 +6. Claim reference number: [if known]
 +
 +Please furnish certified copies of:
 +
 +(1) My family's eligibility status and the SECC 2011 basis
 +    on which PMJAY cover was granted or denied.
 +(2) The pre-authorisation approval and the package code and
 +    approved amount for the above hospitalisation.
 +(3) The current status of my claim reference number and the
 +    date it entered each stage.
 +(4) The exact recorded reason for any denial or delay, the
 +    scheme rule it relies on, and the name of the officer who
 +    recorded it.
 +(5) The projected date of payment to the hospital or the
 +    next stage of the claim.
 +
 +I am a citizen of India. The required fee of Rs.10 is paid
 +by [Indian Postal Order / cash / electronic means].
 +
 +Place: [city]          Signature: [yours]
 +Date: [date]           Name: [full name]
 +</code>
 +
 +===== Step 5: Pay the fee =====
 +
 +The RTI application fee for Central Government public authorities is **Rs.10**, payable by cash, demand draft, Indian Postal Order, or electronic means, under the RTI Rules 2012. State rules can differ slightly, so check your state's RTI rules for the exact fee and mode.
 +
 +If you hold a **BPL card**, you are exempt from both the application fee and the information fee. Attach a copy of your BPL certificate with the application. This exemption comes from RTI Rules 2012 Rule 5 read with the proviso to section 7(5) of the RTI Act.
 +
 +If you are not sure how to pay or where to submit, see [[file-rti-online-india|how to file an RTI online]] for the full filing walk-through.
 +
 +===== Step 6: Know the deadline =====
 +
 +The authority must reply within **30 days** of receiving your application, under section 7(1) of the RTI Act. If your case involves life or liberty, the proviso says the reply must come within **48 hours**. A stuck hospital claim after a surgery can sometimes meet this bar, so state it plainly in your application if there is urgency.
 +
 +===== Step 7: Escalate if there is no reply =====
 +
 +If you get no reply, or a reply you believe is wrong, there is a clear ladder:
 +
 +  - **First appeal** — file with the First Appellate Authority under section 19(1) within 30 days of the deadline passing. The PIO's reply must name this authority.
 +  - **Second appeal** — if the first appeal fails, file a second appeal under section 19(3). For SHA matters, this goes to your **State Information Commission**. For NHA matters, it goes to the **Central Information Commission**.
 +
 +This is the escalation ladder: authority, then appellate authority, then the Information Commission. Each step is a written application, not a court case. You do not need a lawyer.
 +
 +For a worked example of a denial-specific application, see [[rti-for-ayushman-bharat-claim-denial|the Ayushman Bharat claim denial RTI guide]], and for a ready-to-adapt sample see [[guide:applicant:application:sample:ayushman-bharat|the sample Ayushman Bharat application]].
 +
 +===== Common mistakes =====
 +
 +  - **Filing only at the hospital.** The hospital is not a public authority for RTI purposes. File at the SHA and the NHA.
 +  - **Skipping the eligibility proof chain.** Many denials are actually eligibility disputes in disguise. Always ask for the SECC 2011 basis, not just the claim status.
 +  - **Vague questions.** "Why is my claim pending?" gets a vague answer. Use the five precise questions above.
 +  - **Ignoring the grievance system.** File the CGRMS grievance and note the number in your RTI. The two tracks reinforce each other.
 +  - **Missing the first-appeal window.** If you wait too long, you lose the right to appeal. Mark the 30-day deadline the day you file.
 +
 +===== Pro tips =====
 +
 +  - Use **beneficiary.nha.gov.in** to pull your beneficiary ID and card before you file. A correct ID makes the authority's job easier and your reply faster.
 +  - File a parallel grievance on **cgrms.pmjay.gov.in** and quote that reference number in your RTI. It links the two records.
 +  - Call **14555** and keep the complaint number. It is free, 24 hours, and the call log itself is a record.
 +  - If you also have a CGHS angle, the parallel guide at [[rti-for-cghs-empanelment|the CGHS RTI guide]] covers that scheme.
 +  - Keep one folder: application copy, fee proof, posting receipt, grievance number, helpline complaint number, and every reply. The paper trail is your evidence at the appeal stage.
 +
 +===== FAQ =====
 +
 +  - **Q: I paid out of pocket because the card did not work. Can RTI get me reimbursement?** The RTI gets you the records and the reason. It does not itself order payment. Use the RTI reply as proof, then file a grievance and, if needed, a consumer or service complaint for reimbursement.
 +  - **Q: My state adds extra cover on top of PMJAY. How do I ask about that?** File the RTI to your SHA and ask for the state augmentation scheme order, the top-up amount, and the eligibility rule. See [[scheme-state:ayushman-bharat:start|your state's PMJAY scheme details]] for the starting point.
 +  - **Q: The hospital says the claim is stuck at NHA, not the state. Where do I file?** File at the NHA. The NHA is a public authority under section 2(h)(d) and has its own PIO. Use the same five questions.
 +  - **Q: I am BPL. Do I pay the fee?** No. Attach your BPL certificate and the fee is waived under RTI Rules 2012 Rule 5.
 +  - **Q: How long until I get an answer?** 30 days under section 7(1), or 48 hours if life or liberty is at stake.
 +
 +===== Sources =====
 +
 +  - PIB — Cabinet approval restructuring NHA as attached office (2 January 2019): https://pib.gov.in/Pressreleaseshare.aspx?PRID=1558214
 +  - MoHFW — Cabinet approval: PMJAY cover for all senior citizens aged 70 and above (11 September 2024): https://www.mohfw.gov.in/?q=en%2Fpressrelease-64
 +  - Department of Legal Affairs — RTI Act fee (Rs.10) and BPL exemption: https://legalaffairs.gov.in/rti/fee-required-under-rti-act
 +  - NHA — Grievance Redressal Guidelines Office Memorandum (December 2021): https://nha.gov.in/img/resources/OM-Grievance-Redressal-Guideline-Dec-2021.pdf
 +  - PIB — Health Benefit Package 2.2 revision (October 2021): https://pib.gov.in/Pressreleaseshare.aspx?PRID=1761175
 +  - NHA beneficiary portal: https://beneficiary.nha.gov.in/
 +  - PMJAY grievance portal (CGRMS): https://cgrms.pmjay.gov.in
 +  - RTI Act 2005 full text (sections 2(h), 4(1)(b), 5, 7, 19): https://indiankanoon.org/doc/277989/
 +
 +//Last reviewed: 3 July 2026.//
 +
 +{{tag>rti for ayushman bharat claim citizen-rti rti-template pmjay nha sha}}
 +
 +If this guide helped you get a stuck claim moving, take the next step with [[https://righttoinformation.wiki/book|The RTI Playbook]] — a plain-language walk-through for filing, appealing, and winning information requests. And if you believe free legal know-how should stay free for every family, please consider donating to support this work.