36,229 Hospitals on Paper. Rs 1.21 Lakh Crore in Unpaid Bills. 1,184 Hospitals De-Empanelled for Fraud.
Ayushman Bharat PM-JAY promises Rs 5 lakh cashless health coverage to India’s bottom 40% families. On paper, it is the world’s largest government health insurance scheme — covering 11.69 crore hospital admissions since launch.
The reality on the ground is different. 600+ private hospitals in Haryana stopped treating PMJAY patients because the government owes them Rs 500 crore. A hospital in Patna performed unauthorized hysterectomies on 6 women to file fake claims. Three in four grievances filed by beneficiaries are about hospitals demanding out-of-pocket payment for what is supposed to be free treatment.
This is an honest, data-backed guide to what Ayushman Bharat actually delivers in 2026 — the coverage that works, the gaps you need to know about, and exactly what to do when a hospital refuses you.
What Ayushman Bharat Actually Covers
The scheme’s promise is straightforward:
| Feature | Details |
|---|---|
| Coverage amount | Rs 5 lakh per family per year |
| Treatment packages | 1,929 procedures across 27 specialties |
| Type | Cashless at empanelled hospitals |
| Pre-existing conditions | Covered from day one |
| Waiting period | None |
| Age limit | None |
| Premium | Zero (fully government-funded) |
Who Is Eligible
- Bottom 40% families identified in the Socio-Economic Caste Census (SECC) 2011 data
- All senior citizens aged 70+ regardless of income (added September 2024 under Ayushman Vayo Vandana, covering an estimated 4.5 crore additional people)
The coverage itself is genuinely comprehensive. Pre-existing conditions are covered from day one — something private health insurance plans make you wait 2-4 years for. No premium. No co-payment in the policy design.
The problem is not what the scheme covers. The problem is what happens when you actually try to use it.
The Hospital List Problem: Numbers vs Reality
PMJAY’s official portal lists 36,229 empanelled hospitals as of February 2026.
| Hospital Type | Count | Percentage |
|---|---|---|
| Public hospitals | 19,483 | 53.8% |
| Private hospitals | 16,746 | 46.2% |
| Total empanelled | 36,229 | 100% |
| De-empanelled (fraud) | 1,184 | — |
| Suspended | 549 | — |
| Penalized | 1,504 | — |
That 36,229 number hides three critical problems:
1. Major private hospitals are not on the list. Max Healthcare, Fortis, Medanta, and most Apollo branches are not empanelled. The package rates PMJAY pays are so low that large private hospitals cannot participate without losing money on every patient.
2. Empanelled does not mean accepting. Over 600 private hospitals in Haryana collectively stopped treating PMJAY patients in 2025-26 because the state government owed them Rs 500 crore in unpaid bills. The hospitals are technically empanelled. They just will not treat you.
3. Government hospitals are overcrowded. With private hospitals dropping out, the load shifts to government hospitals that are already running beyond capacity. Wait times for elective procedures stretch into months.
Why Hospitals Refuse: Package Rates vs Real Costs
This is the core structural problem. PMJAY’s package rates were set years ago and have not kept pace with medical inflation. Here is what PMJAY pays versus what procedures actually cost at a mid-tier private hospital:
| Procedure | PMJAY Package Rate | Actual Market Cost | Gap |
|---|---|---|---|
| Cardiac bypass (CABG) | Rs 1,20,000 | Rs 3,00,000 - 6,50,000 | 60-82% |
| Knee replacement (single) | Rs 80,000 | Rs 2,50,000 - 4,00,000 | 68-80% |
| Hip replacement | Rs 75,000 | Rs 2,50,000 - 3,50,000 | 70-79% |
| Cataract surgery | Rs 15,000 | Rs 25,000 - 60,000 | 40-75% |
| Cancer chemotherapy (per cycle) | Rs 12,000 - 25,000 | Rs 40,000 - 1,50,000 | 70-83% |
| Normal delivery | Rs 9,000 | Rs 20,000 - 50,000 | 55-82% |
| C-section delivery | Rs 18,000 | Rs 40,000 - 1,20,000 | 55-85% |
| Appendectomy (laparoscopic) | Rs 22,000 | Rs 50,000 - 90,000 | 56-76% |
| Hernia repair | Rs 17,000 | Rs 40,000 - 70,000 | 57-76% |
| Dialysis (per session) | Rs 1,500 | Rs 2,000 - 4,000 | 25-63% |
When the government pays Rs 1.2 lakh for a cardiac bypass that costs the hospital Rs 3-6.5 lakh, the hospital loses Rs 1.8-5.3 lakh per patient. No business model survives that math.
The hospitals that stay empanelled at these rates either:
- Are government hospitals (costs absorbed by the state)
- Are small private hospitals that cut corners on consumables, implant quality, or post-operative care
- Demand out-of-pocket payment from patients to bridge the gap (which is illegal under PMJAY rules)
This is why having an Ayushman card does not mean you get the same treatment as someone with private cashless health insurance walking into a top-tier hospital.
The Fraud Problem
Ayushman Bharat’s scale has attracted systematic fraud. The numbers as of February 2026:
| Fraud Metric | Number |
|---|---|
| Hospitals de-empanelled for fraud | 1,184 |
| Hospitals currently suspended | 549 |
| Hospitals penalized | 1,504 |
| Total penalties levied | Rs 122 crore |
| Claims rejected for fraud | 3.56 lakh |
| Value of rejected fraudulent claims | Rs 643 crore |
| Fraud prevented by AI (SAHI) | Rs 630 crore |
What the Fraud Looks Like
Ghost patients: 400 fake Ayushman cards were used to admit 250 patients in Lucknow who either did not exist or did not need treatment. The hospital billed the government for procedures never performed.
Unnecessary surgeries: In March 2026, a Patna hospital performed unauthorized hysterectomies on 6 women to file fake PMJAY claims. The women came in for minor complaints. The hospital saw an opportunity to bill Rs 25,000-30,000 per hysterectomy under PMJAY.
Upcoding: Hospitals perform a minor procedure but bill for a more expensive package. A diagnostic endoscopy gets billed as a surgical procedure. A single-day observation gets coded as a multi-day admission.
The government’s response — the SAHI (System for AI-based Hospital Intelligence) initiative launched in February 2026 — uses machine learning to flag suspicious patterns. It has identified and prevented Rs 630 crore in fraudulent claims so far. But the system is new, and the fraud has been running for years.
Payment Delays: Rs 1.21 Lakh Crore Pending
Pending PMJAY bills across states have crossed Rs 1.21 lakh crore. This is the single biggest reason private hospitals refuse PMJAY patients.
The payment cycle is supposed to work like this: hospital treats patient, submits claim, state health agency processes payment within 15-30 days.
In practice, payment delays of 6+ months are routine. Some states owe hospitals over 12 months of pending claims.
The Haryana crisis is the most visible example: 600+ private hospitals stopped treating PMJAY patients because the state government owed them Rs 500 crore. But similar tensions exist in Rajasthan, Uttarakhand, Jharkhand, and Chhattisgarh.
For the patient, payment delays create a cascade:
- Hospitals do not get paid
- Hospitals stop accepting PMJAY patients
- Remaining hospitals get overloaded
- Wait times increase
- Hospitals that continue demand out-of-pocket payment from patients
The patient — who is by definition from the bottom 40% of Indian families — is the one who suffers.
What Actually Happens at the Hospital
Here is the realistic patient experience when you show up at a PMJAY-empanelled hospital in 2026:
Best case (government hospital, available capacity): You show your Ayushman card, get admitted, get treated. The hospital processes the claim. You pay nothing. This works as designed, especially for common procedures at well-run district hospitals.
Common case (private hospital, common procedure): You show your Ayushman card. The hospital insurance desk says they accept PMJAY but asks for a “deposit” of Rs 5,000-15,000 for “consumables” or “non-covered items.” This is technically illegal — PMJAY is fully cashless — but three in four grievances from beneficiaries are about exactly this.
Worst case (private hospital, expensive procedure): The hospital says it is empanelled but “not currently accepting PMJAY patients” for your procedure. Or the hospital says the package rate does not cover your specific condition. Or the hospital accepts you but pushes you toward a non-PMJAY paid treatment option. You are left to find another hospital or pay out of pocket.
If you face payment demands or treatment denial, you need to know how to fight back — similar to how private insurance claims get rejected and can be contested.
How to Check Your Eligibility and Find Hospitals
Step 1: Check Eligibility
- Visit mera.pmjay.gov.in
- Enter the mobile number linked to your ration card or SECC data
- The portal will confirm if your family is eligible
- Alternatively, call 14555 (24x7 helpline)
Step 2: Get Your Ayushman Card
- Visit your nearest Common Service Centre (CSC) with Aadhaar and ration card
- Or visit an Ayushman Mitra at any empanelled hospital
- E-card is generated instantly via Aadhaar e-KYC
- Card is free — do not pay any agent who demands money for it
Step 3: Find Empanelled Hospitals
- Go to hospitals.pmjay.gov.in
- Select your state, district, and hospital type
- Critical: Call the hospital before visiting. Ask specifically: “Are you currently accepting PMJAY patients for [your procedure]?”
- Being on the portal list does not guarantee the hospital will treat you under PMJAY
Step 4: At the Hospital
- Show your Ayushman card and Aadhaar at the PMJAY/insurance desk
- The hospital verifies your identity and coverage via the PMJAY IT system
- Pre-authorization is processed digitally
- You should pay nothing — no deposit, no consumable charges, no “VIP room upgrade” fees
How to File a Complaint When Treatment Is Denied
If a hospital refuses treatment or demands money, use the three-tier grievance system:
Tier 1: District Level
- Call the PMJAY helpline at 14555 (available 24x7)
- Your complaint is registered and assigned to a District Grievance Redressal Officer
- Expected resolution: 15 days
Tier 2: State Level
- If unresolved at district level, escalate to the State Health Agency (SHA)
- File on the CGRMS portal at cgrms.pmjay.gov.in
- Expected resolution: 30 days
Tier 3: National Level
- Unresolved complaints go to the National Health Authority (NHA)
- File via the CGRMS portal with your district and state complaint reference numbers
- NHA intervenes with the state government directly
Documentation You Need
Keep records of everything:
- Hospital name, address, and empanelment number
- Date and time of visit
- Name and designation of staff who refused treatment or demanded money
- Written refusal (if the hospital provides one)
- Receipts for any money paid
- Photos or screenshots of the hospital’s PMJAY empanelment on the portal
In practice, resolution takes 60-90 days, not the 15-30 days promised. But documented complaints do lead to action — hospitals risk de-empanelment, and staff risk penalties.
The Bottom Line: What Ayushman Bharat Is and What It Is Not
What it is: A genuine safety net that prevents the poorest 40% of Indian families from going bankrupt due to hospitalization. For basic procedures at government hospitals, it works. 11.69 crore admissions have been processed. Real people have received real treatment at zero cost.
What it is not: An equivalent of private health insurance. The hospital network is limited. The best hospitals do not participate. Package rates have not kept up with costs. Payment delays cause hospitals to refuse patients. Fraud is real and widespread.
If You Qualify for Ayushman Bharat
- Get your card. It is free. Use it for hospitalizations at government hospitals and well-run empanelled private hospitals.
- If you can afford it, also buy a private super top-up health insurance policy with Rs 5-10 lakh coverage. It costs Rs 3,000-8,000 per year and gives you access to better hospitals when it matters.
- For parents above 60, the September 2024 expansion means all 70+ seniors qualify for Ayushman Bharat regardless of income. Use it as supplementary coverage alongside their private policy.
If You Do Not Qualify
- You need private health insurance. There is no shortcut. Rs 5-10 lakh base cover plus a super top-up is the minimum responsible configuration.
- PMJAY is not available to you, and the hospitals that accept PMJAY are unlikely to be the hospitals you want to go to for serious procedures.
The scheme’s intent is right. The structural problems — underfunded package rates, payment delays, and fraud — are fixable. But as of 2026, Ayushman Bharat is a safety net with holes. Know where the holes are before you fall through one.