Understanding Your Rights as an Ayushman Beneficiary
Having an Ayushman Card is a powerful tool, but one of the most stressful situations a beneficiary can face is when an empanelled hospital refuses to provide cashless treatment. It is crucial to know your rights: **any hospital that is empanelled under the Ayushman Bharat PMJAY scheme is contractually obligated to provide free and cashless treatment for covered procedures to all eligible beneficiaries.**
Denying treatment without a valid medical or administrative reason is a serious violation. The government has established a robust Grievance Redressal Mechanism to protect your rights. This guide will provide clear, actionable steps on what to do immediately if you face such a situation. Before you proceed, ensure you understand the standard procedure by reading our guide on how to use your Ayushman card at a hospital.
Immediate Steps to Take at the Hospital
If a hospital staff member denies your Ayushman Card, do not panic. Follow these steps calmly and systematically:
- Speak to the Ayushman Mitra: Immediately go to the hospital's Ayushman Mitra helpdesk. These individuals are trained to handle the scheme's processes. Explain the situation to them. Often, a denial is a result of a miscommunication with the billing or admissions staff, which the Ayushman Mitra can resolve.
- Ask for a Clear Reason: If the Ayushman Mitra also confirms the denial, ask for the specific reason. Common (but not always valid) excuses include "server is down," "package rate is too low," or "bed is not available." Ask them to provide this reason in writing if possible.
- Do Not Pay Cash: Do not agree to pay for the treatment in cash with a promise of reimbursement later. The scheme is designed to be completely cashless, and you should insist on your right to it.
- Call the Helpline from the Hospital: This is the most effective step. While you are still at the hospital, call the Ayushman Bharat toll-free helpline.
How to Formally File a Complaint (Grievance Redressal)
If the issue is not resolved at the hospital level, you must file a formal complaint. There are two primary methods for this:
Method 1: Calling the Toll-Free Helpline
This is the fastest way to register your grievance.
- Dial the national toll-free number: 14555 or 1800-111-565.
- Inform the call center executive about the hospital's name, location, and the issue you are facing.
- Provide your Ayushman Card ID and the patient's details.
- The executive will register your complaint and provide you with a complaint reference number. This often triggers immediate action, with officials contacting the hospital directly.
Method 2: Using the Online Grievance Portal
For a documented complaint with evidence, the online portal is the best option.
- Visit the official PMJAY Grievance Redressal Portal: grievance.pmjay.gov.in.
- Click on 'Register Your Grievance' and select 'PMJAY' from the options.
- Fill out the complaint form with all the required details: your personal information, details of the complaint, the hospital's name, and the state.
- You can also upload supporting documents if you have any (like a written denial from the hospital).
- After submission, you will receive a **Unique Grievance Number (UGN)**. You can use this UGN to track the status of your complaint on the same portal.
What Happens After You Complain?
Every complaint is taken very seriously. Once you file a grievance, it is forwarded to the concerned State Health Agency (SHA) for investigation. The authorities will contact the hospital to seek an explanation. If the hospital is found to be at fault, it can face penalties, including suspension or permanent de-empanelment from the scheme. Your issue will be resolved as per the scheme's guidelines.
Frequently Asked Questions (FAQs)
Q. Can a hospital deny treatment if their server is down?
While technical issues can cause delays, they are not a valid reason for outright denial of treatment, especially in an emergency. Hospitals have offline procedures to follow in such cases. If this reason is given, you should still call the helpline.
Q. What if a specific treatment is not covered by the scheme?
The scheme covers a specific list of over 1,900 procedures. If a particular treatment is genuinely not on this list, the hospital is not obligated to provide it cashless. The Ayushman Mitra can provide you with the list of covered procedures.