The Rs 5 Lakh Limit Is No Longer Enough
A Parliamentary Standing Committee on Health and Family Welfare has recommended a significant increase in India's flagship health insurance scheme. In its 172nd Report, the committee proposed raising the insurance coverage under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana from the existing Rs 5 lakh to Rs 10 lakh per family per year. The reason is straightforward: the current limit is no longer sufficient to cover the cost of advanced medical treatments that Indian families increasingly need.
This recommendation, if implemented, would affect over 55 crore beneficiaries across the country. It would also reshape the landscape for health insurance claims, particularly for families who currently find themselves paying substantial out-of-pocket expenses despite being covered under the scheme.
Why the Current Rs 5 Lakh Cover Falls Short
The committee observed that rapid advancements in medical technology and the rising cost of high-end procedures have pushed treatment expenses well beyond the scheme's current coverage limit. Specific treatments cited include organ transplants, advanced cardiac surgeries, cancer immunotherapy, and other specialised critical care procedures.
Medical inflation in India is estimated at 12 to 14 percent annually, among the highest globally. A single organ transplant or advanced cancer treatment can easily cost Rs 10 lakh to Rs 20 lakh or more. Under the current Rs 5 lakh cap, families covered by Ayushman Bharat are forced to borrow, sell assets, or simply forgo treatment when costs exceed the limit.
The committee noted that despite being covered under the scheme, many beneficiaries continue to incur substantial out-of-pocket expenditure. This defeats the fundamental purpose of a cashless health insurance programme: to protect economically vulnerable families from catastrophic healthcare spending.
What Doubling the Cover Would Change
If the government accepts the committee's recommendation, several important shifts would occur for beneficiaries and their claims.
First, access to advanced treatments would improve. Families requiring organ transplants, complex cardiac interventions, or cancer therapies would have a realistic chance of receiving full cashless treatment without exhausting their coverage in the first few days of hospitalisation.
Second, the financial burden on states would increase, but so would the protection for families. The current scheme operates on a 60:40 cost-sharing agreement between the centre and states. Doubling the cover would require proportional increases in budgetary allocation, but the committee argued that the alternative, leaving families to bear crushing medical debt, is far worse.
Third, the recommendation includes a call for periodic review of insurance limits in line with medical inflation. This is crucial. A static coverage amount, even Rs 10 lakh, will become inadequate again within a few years if medical costs continue rising at their current pace. The committee wants the scheme to remain effective and relevant through regular upward revisions.
The Claim Rejection Problem Under PM-JAY
At Tatkal Claims, we handle health insurance disputes across all categories, including government-sponsored schemes. While Ayushman Bharat has been transformative in expanding healthcare access, beneficiaries still face significant claim-related challenges.
The most common issues include hospitals refusing cashless treatment despite empanelment, delays in pre-authorisation approvals, disputes over package rates, and arbitrary exclusions for procedures that should be covered. When the coverage limit is only Rs 5 lakh, these disputes become even more devastating because the family's financial margin for error is razor-thin.
A higher coverage limit would not eliminate these problems, but it would reduce their severity. When a family has Rs 10 lakh instead of Rs 5 lakh, a disputed claim for Rs 50,000 represents 5 percent of their cover rather than 10 percent. The breathing room matters.
What the Committee Also Recommended
Beyond doubling the cover, the committee highlighted the importance of strengthening healthcare infrastructure, expanding the network of empanelled hospitals, and ensuring timely claim settlements. These are not afterthoughts. They are essential complements to higher coverage.
A Rs 10 lakh cover is meaningless if empanelled hospitals are not available in your district, if pre-authorisation takes weeks, or if claim settlements are delayed so long that families must pay upfront and wait months for reimbursement. The committee recognised that increasing financial coverage must be matched by better access to quality healthcare services, diagnostics, and specialist care across both urban and rural regions.
Who Is Currently Covered Under PM-JAY
Ayushman Bharat PM-JAY, launched in September 2018, is the world's largest government-funded health assurance programme. It currently covers over 10.74 crore poor and vulnerable families, approximately 50 crore beneficiaries, based on deprivation and occupational criteria from the Socio-Economic Caste Census 2011.
The scheme provides cashless secondary and tertiary care hospitalisation across a network of public and empanelled private hospitals. There is no cap on family size, no age restrictions, and all pre-existing conditions are covered from day one. Benefits are portable across the country.
In September 2024, the Union Cabinet expanded the scheme to include all senior citizens above 70 years of age, irrespective of their socio-economic status. These seniors receive a separate Rs 5 lakh coverage exclusively for themselves, which does not need to be shared with other family members below 70.
What Is Not Covered Under PM-JAY
Even with doubled coverage, beneficiaries must understand the scheme's exclusions. The following are not covered under Ayushman Bharat PM-JAY.
Out-patient department expenses, including routine doctor consultations and diagnostic tests outside hospitalisation. Drug rehabilitation programmes. Cosmetic surgeries. Fertility treatments. Individual diagnostics for evaluation purposes. Organ transplants, which is notable given that the committee specifically cited transplants as a driver for higher coverage.
This last point is important. If organ transplants remain excluded even after the cover is doubled, the committee's objective of protecting families from catastrophic costs for these procedures would not be fully achieved. Beneficiaries should monitor whether the government addresses this exclusion when implementing the recommendation.
How to Check Your Eligibility and Access Benefits
If you believe you may be eligible for Ayushman Bharat PM-JAY, here is how to verify and access your benefits.
Visit the official PMJAY website at pmjay.gov.in and click on Am I Eligible. Enter your mobile number or ration card number for instant confirmation. If eligible, you can generate your Ayushman Card through the portal or by visiting a nearby Common Service Centre or Ayushman Mitra kiosk at an empanelled hospital.
You will need your Aadhaar card or government-approved photo ID, along with your ration card or family ID if applicable. Biometric verification is required at the kiosk. Once verified, your Ayushman Card with a unique AB-PMJAY ID is printed and can be used for cashless treatment at any empanelled hospital across India.
For inquiries or support, contact the PMJAY helpline at 14555 or 1800-111-565.
What to Do If Your PM-JAY Claim Is Denied or Delayed
Despite the scheme's benefits, claim disputes occur. If you or your family member faces a denial or delay in PM-JAY cashless treatment, take the following steps.
First, demand a written reason for the denial from the hospital's PM-JAY desk or the insurer's representative. The reason must cite the specific package or exclusion that justifies the refusal.
Second, verify that the hospital is empanelled under PM-JAY and that the procedure you require is included in the scheme's package list. Over 1,929 procedures are covered across 25 specialities, but not all treatments fall within the scheme.
Third, if the hospital refuses cashless treatment without valid grounds, escalate to the district health authority or the state health agency responsible for PM-JAY implementation. Each state has a designated agency that oversees empanelled hospitals and can intervene in disputes.
Fourth, if pre-authorisation is delayed beyond the prescribed timeline, contact the PMJAY helpline and register a formal complaint. Delays in critical care can be life-threatening, and the scheme has mechanisms to fast-track emergency approvals.
Fifth, if you have exhausted these channels without resolution, consider approaching the Insurance Ombudsman or seeking legal assistance. At Tatkal Claims, we handle disputes across both private and government-sponsored health insurance schemes, including PM-JAY claim denials.
Bottom Line
The Parliamentary Standing Committee's recommendation to double Ayushman Bharat PM-JAY coverage from Rs 5 lakh to Rs 10 lakh is a recognition of a reality that millions of Indian families already know: healthcare costs have outpaced insurance protection. For families facing organ transplants, cancer therapies, and advanced cardiac procedures, the current limit is simply inadequate.
If implemented, this change would provide meaningful financial relief to over 55 crore beneficiaries. But coverage alone is not enough. The scheme must also address infrastructure gaps, empanelment quality, claim settlement speed, and the exclusion of critical procedures like organ transplants.
For policyholders navigating the complex world of health insurance claims, whether under private policies or government schemes, the fundamental principle remains the same: know your coverage, understand your exclusions, document everything, and do not accept an unjust denial without a fight.
---
Facing a health insurance claim denial, delay, or dispute under Ayushman Bharat PM-JAY or a private policy? Contact our legal team at Tatkal Claims for expert assistance in securing the benefits you and your family deserve.