PMJAY Medical Insurance

The Prime Minister Health Insurance Scheme, officially known as Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY), is a government-backed health insurance program aimed at providing affordable healthcare to eligible individuals and families. As a major initiative under the PM Medical Insurance Scheme, PMJAY offers financial protection for hospitalisation expenses to over 50 crore Indians.

In this blog, we will look at the key features, benefits, eligibility criteria, and enrollment process of the PMJAY Health Insurance plan. We will also explore how private insurers, like Bajaj General Insurance, work with this scheme to help people access healthcare, especially senior citizens and those with critical illnesses.

What is PMJAY Medical Insurance?

Launched in September 2018 by the Government of India, the Pradhan Mantri Health Insurance Scheme, popularly known as PMJAY Medical Insurance, aims to provide financial protection to the economically weaker sections of society. It covers hospitalisation expenses up to INR5 lakh per family per year for secondary and tertiary medical care.

PMJAY is the largest government-funded health insurance program in the world, aimed at helping the poorest 40% of India's population. Its main goal is to lower out-of-pocket healthcare costs and offer cashless services at public and private hospitals that are part of the program.

Objectives of the PM Medical Insurance Scheme

The main goals of the PMJAY Health Insurance scheme include:

1. Ensuring equitable access to healthcare for vulnerable populations

2. Providing cashless hospitalisation at empanelled facilities

3. Covering pre-existing conditions from day one

4. Enhancing the quality of life by reducing healthcare-induced financial distress

5. Creating a strong, inclusive healthcare infrastructure in India

Key Features of PMJAY Health Insurance

Here are the most significant features of the PMJAY Medical Insurance:

1. Coverage of ₹5 lakh per family per annum

2. Covers over 10 crore families, targeting around 50 crore individuals

3. No cap on family size, gender, or age

4. Cashless treatment is available at more than 28,000+ empanelled hospitals

5. 3 days Pre and 15 post-hospitalisation expenses covered

6. Day-one coverage for all pre-existing conditions

7. Portable benefits across India – beneficiaries can access treatment anywhere

8. Services available for more than 1500 medical procedures

9. Includes COVID-19 treatment

These features make PMJAY a well-rounded and inclusive Prime Minister Health Insurance initiative.

Eligibility Criteria for PMJAY

Eligibility for the PMJAY Health Insurance scheme is based on data from the Socio-Economic Caste Census (SECC) 2011. Here’s how it works for both rural and urban households:

For Rural Areas:

Families that fall into one or more of these deprivation categories are eligible:

1. Families living in a single-room house with kutcha walls and roof

2. No adult member between the ages of 16 and 59

3. Households with disabled members and no able-bodied adult

4. SC/ST households

5. Landless households relying on manual labour

6. Destitute, bonded labourers, and manual scavengers

For Urban Areas:

Eligible beneficiaries include individuals working in the following occupations:

1. Street vendors, hawkers, and cobblers

2. Domestic workers, ragpickers, sweepers

3. Carpenters, electricians, plumbers

4. Mechanics, construction workers

5. Drivers, transport workers, and delivery boys

To check if you are eligible, visit the official PMJAY portal (www.pmjay.gov.in) or dial 14555 / 1800-111-565.

What is Covered Under Ayushman Bharat Yojana Scheme?

The PM Medical Insurance Scheme is comprehensive and includes:

1. Hospitalisation (secondary and tertiary care)

2. Pre- and post-hospitalisation (3 and 15 days)

3. Diagnostics, medicines, implants, room rent, ICU/OT charges

4. Ambulance and food services

5. Complications during treatment

6. COVID-19 treatment is included

This makes PMJAY Medical Insurance one of the most inclusive and robust Prime Minister Health Insurance plans available to low-income families.

What is Not Covered Under Ayushman Bharat Yojana Scheme?

Though generous, the PMJAY plan does not cover:

1. Outpatient treatment (OPD)

2. Cosmetic procedures

3. Fertility treatments

4. Organ transplant

5. Drug rehabilitation

To fill these gaps, families can opt for top-up coverage through private insurers like Bajaj General Insurance, which offers advanced health insurance options tailored to their specific needs.

Enrolment Process for PMJAY Medical Insurance

Unlike traditional insurance plans, PMJAY Health Insurance is entitlement-based, meaning you don’t need to apply if you are already listed in the SECC database or were covered under RSBY (Rashtriya Swasthya Bima Yojana).

How to Check Eligibility and Get Enrolled:

1. Visit www.pmjay.gov.in

2. Click on “Am I Eligible?”

3. Enter your mobile number and verify with OTP

4. Search using name, ration card number or HHD number

5. If eligible, your details will appear

Alternatively, visit a Common Service Centre (CSC) or an empanelled hospital with identity and address proof to verify eligibility and get your Ayushman Bharat Golden Card.

Documents Required to Apply For Ayushman Bharat Yojana Scheme

Here are the essential documents needed:

1. Aadhaar card or other valid ID proof

2. Ration card or family income certificate

3. Mobile number and address proof

4. SECC ID or RSBY number (if available)

5. Passport-size photograph

PMJAY Golden Card: Your Access to Free Treatment

Once verified, you will be issued a PMJAY Golden Card. This card is your gateway to cashless treatment. Simply present it at any of the empanelled hospitals to avail free medical care.

You can download your card from mera.pmjay.gov.in using your registered mobile number.

Hospitalisation Process Under PMJAY

1. Visit an empanelled hospital with your Golden Card.

2. Contact the Ayushman Mitra at the hospital.

3. The Mitra will verify your details and initiate the pre-authorisation process.

4. On approval, you will be admitted and treated without paying anything.

5. Post-treatment, the hospital settles the bill directly with the PMJAY authorities.

PMJAY and Health Insurance for Senior Citizens

In 2024, a historic move was announced – PMJAY would now cover senior citizens above 70 years, irrespective of family income. This was a welcome step as seniors are often denied private health insurance due to pre-existing conditions or high premiums.

The Prime Minister Health Insurance Scheme now provides free medical cover of ₹5 lakh even for the elderly. This facility falls under the Ayushman Vay Vandana Yojana and aligns with the vision of equitable and accessible healthcare for all.

However, for enhanced coverage (e.g., OPD, dental, home care), elderly citizens may consider supplementary plans from Bajaj General Insurance. The health insurance for senior citizens plans at Bajaj General Insurance fills the critical gaps and offers peace of mind with:

1. Coverage for pre- and post-hospitalisation

2. Wellness benefits

3. Annual check-ups

4. Chronic illness management

5. Cashless network across 18,400+ hospitals

Critical Illnesses Covered Under PMJAY Health Insurance

The scheme covers over 1500 medical procedures. Here are a few critical treatments included:

1. Cancer treatment (including chemotherapy, radiotherapy)

2. Cardiac procedures like bypass surgery

3. COVID-19 care

4. Orthopaedic surgeries

5. Neurological treatments

6. Dialysis for kidney patients

7. Liver and gastrointestinal diseases

8. Maternity care and neonatal services

9. Trauma and burn management

This makes PMJAY Medical Insurance a powerful tool for low-income families battling life-threatening conditions.

How PMJAY Works with Other Schemes Like PMJJBY Insurance?

While PMJAY Health Insurance covers hospitalisation costs, other government schemes provide coverage for life or accidents. For instance:

1. PMJJBY Insurance (Pradhan Mantri Jeevan Jyoti Bima Yojana): Life insurance cover of ₹2 lakh at just ₹436 per year.

2. PMSBY (Pradhan Mantri Suraksha Bima Yojana): Accidental death and disability cover of ₹2 lakh at just ₹12 per year.

Together, these form a safety net for India’s poor and vulnerable families.

Unified Health Interface (UHI) & ABHA – The Future of Digital Healthcare

To streamline healthcare access under PMJAY, the government has introduced ABHA ID (Ayushman Bharat Health Account) – a 14-digit health ID that stores your digital medical records. It allows easy sharing with doctors, insurers, and hospitals for seamless care.

The Unified Health Interface (UHI) ensures:

1. One digital platform for booking appointments, tests, and consultations

2. Cross-platform interoperability between public and private healthcare systems

3. Faster cashless claim approvals through ABHA-linked policies

You can generate your ABHA ID online or via mobile apps and start building your digital health vault.

Real Impact: How PMJAY Has Changed Lives?

1. Over 21 crore Ayushman Cards have been issued since 2018.

2. More than 4 crore hospital admissions covered.

3. PMJAY beneficiaries have saved thousands of crores in treatment costs.

4. COVID-19 response strengthened through this scheme.

In rural and underserved areas, PMJAY has ensured access to quality care, reducing medical debt and improving healthcare-seeking behaviour.

Role of Bajaj General Insurance in Strengthening India’s Health Ecosystem

While the government takes giant strides with PMJAY, Bajaj General Insurance plays a vital role in enhancing the system. Here’s how:

1. Supplemental plans for uncovered treatments under PMJAY (e.g., OPD, transplants, ICU ventilator cover)

2. Health insurance for senior citizens with tailored wellness programs

3. Critical illness policies for diseases not covered by PMJAY

4. Digital tools like health apps, online claim submission, and 24x7 customer support

5. Portability benefits and add-on riders for more personalised plans

Whether you are covered under PMJAY or not, Bajaj General Insurance can help you build a holistic health shield for you and your loved ones.

How Can PMJAY and Private Insurance Go Hand in Hand?

While PMJAY Health Insurance is a game changer, pairing it with private insurance helps build a comprehensive healthcare plan. Bajaj General Insurance offers the flexibility, enhanced features, and broader coverage that ensure:

1. Continuity of care for non-hospitalised patients

2. Access to advanced medical facilities

3. Peace of mind for families with senior citizens

4. Protection against exclusions under PMJAY

This dual-layered approach helps families enjoy financial security and health protection without compromise.

Conclusion

The PMJAY Medical Insurance Scheme plays a significant role in expanding healthcare access across India. The Prime Minister's Health Insurance Scheme aims to make essential medical services more affordable for millions. While the scheme covers a large section of the population, there is still scope to enhance coverage and support.

Bajaj General Insurance, as a private insurer, can complement government efforts by offering additional health insurance options tailored to individual needs, including plans for senior citizens and those covering critical illnesses. Exploring both government and private health coverage can help individuals and families stay better prepared for medical expenses.

Frequently Asked Questions

1: What is the PM Medical Insurance Scheme and who is it for?

The PM Medical Insurance Scheme, also known as Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY), is a government-funded health insurance initiative. It provides cashless treatment up to ₹5 lakh per year to economically vulnerable families across India. It’s designed especially for the bottom 40% of the population based on the SECC 2011 data. The scheme benefits poor, rural, and urban occupational groups who otherwise can't afford hospital care. PMJAY Health Insurance also ensures accessibility to both public and empanelled private hospitals for eligible citizens. It is India’s largest Prime Minister Health Insurance Scheme to date.

2: How can I check if I’m eligible for PMJAY Medical Insurance?

To check eligibility for PMJAY Medical Insurance, visit the official website pmjay.gov.in. Click the “Am I Eligible” section, enter your mobile number, and verify via OTP. You can search using your name, ration card number, or HHD number. Alternatively, you can visit a Common Service Centre (CSC) or call the PMJAY helpline at 14555 or 1800-111-565. Eligibility is determined using SECC 2011 data. Those previously covered under the RSBY scheme are also likely eligible under the Prime Minister Health Insurance Scheme.

3: What does the PMJAY Health Insurance scheme cover?

The PMJAY Health Insurance scheme covers a wide range of healthcare services. These include hospitalisation expenses, surgeries, diagnostics, pre- and post-hospitalisation care, ICU charges, specialist consultations, room charges, medications, and even food during the stay. It offers cashless treatment for over 1,500 procedures, including major illnesses like cancer, cardiac surgeries, and COVID-19. The Prime Minister's Health Insurance Scheme is valid across India at empanelled hospitals, allowing families to receive treatment with minimal paperwork and no out-of-pocket expenses.

4: What medical treatments are not covered under PMJAY?

Though PMJAY Medical Insurance offers broad coverage, some treatments are excluded. These include cosmetic surgeries, fertility treatments, organ transplants, outpatient (OPD) services, drug rehabilitation, and diagnostic tests not associated with hospitalisation. High-end and elective procedures not deemed necessary for recovery or life support are generally not covered. For these, individuals can consider supplementary health plans from trusted insurers like Bajaj General Insurance, which offer customised health insurance for senior citizens, critical illness coverage, and enhanced outpatient department (OPD) benefits.

5: How do I apply for a PMJAY Golden Card?

Eligible individuals can get their PMJAY Golden Card through the official PMJAY website or at their nearest Common Service Centre (CSC). Log on to mera.pmjay.gov.in with your registered mobile number, enter the captcha, and choose the HHD code option. Visit a CSC with your HHD number and ID proof. An Ayushman Mitra will verify your details and issue your card for a nominal fee of ₹30. This card enables you to access cashless medical treatment under the Prime Minister Health Insurance Scheme at empanelled hospitals across the country.

6: Can senior citizens avail PMJAY Medical Insurance benefits?

Yes. In a recent expansion, the PM Medical Insurance Scheme now includes senior citizens aged 70 and above, irrespective of their family income. This is a significant move to ensure universal health access to one of the most vulnerable populations. Seniors are now eligible for ₹5 lakh coverage per year under PMJAY Health Insurance. However, for broader protection, including home healthcare, OPD, and annual check-ups, seniors can also opt for supplementary plans from Bajaj General Insurance, which offers extensive health insurance for senior citizens with additional wellness benefits.

7: What is the PMJJBY Insurance, and how is it related to PMJAY?

The PMJJBY Insurance (Pradhan Mantri Jeevan Jyoti Bima Yojana) is a separate government scheme that provides life insurance coverage of ₹2 lakh at just ₹436 annually. Unlike PMJAY Medical Insurance, which covers hospital expenses, PMJJBY is focused on life cover in case of death. Both schemes aim to provide financial security to low-income families. While PMJAY handles medical needs, PMJJBY takes care of the family’s future in case of a breadwinner’s death. Together, they offer a robust Prime Minister Health Insurance Scheme and social protection ecosystem.

8: How does Bajaj General Insurance  complement PMJAY coverage?

While PMJAY Medical Insurance covers basic and tertiary hospital expenses for the poor, there are limitations, such as exclusions for outpatient care, dental care, or organ transplants. Bajaj General Insurance Limited  offers customised health insurance plans for all income groups, including health insurance for senior citizens, top-up plans, critical illness cover, and maternity plans. Their digital tools, extensive hospital network, and quick claim process help bridge the gap between government coverage and comprehensive care.

9: What is the ABHA ID, and how does it help PMJAY beneficiaries?

The ABHA (Ayushman Bharat Health Account) ID is a unique 14-digit number that stores your digital health records securely. Introduced under the Ayushman Bharat Digital Health Mission, it ensures that patients, doctors, and hospitals can share medical information seamlessly. For PMJAY Health Insurance beneficiaries, this means easier claim processing, faster admission, and better follow-ups. It integrates with your Golden Card and helps empanelled hospitals access your treatment history.

10: Can I use PMJAY Medical Insurance at any hospital?

No, you can only use PMJAY Health Insurance at empanelled public and private hospitals that are part of the scheme. As of now, there are over 28,000 empanelled hospitals across India. To find one, visit pmjay.gov.in, go to the hospital list, and filter by state, district, and specialty. You can also contact the Ayushman Mitra at the hospital for assistance. For broader network access, international coverage, and specialised care, consider supplementing PMJAY with a plan from Bajaj General Insurance Limited, especially for senior citizens and critical cases.

11: What happens if I need multiple treatments under PMJAY in a year?

Under the PMJAY Medical Insurance scheme, the annual coverage limit is ₹5 lakh per family, not per individual. This means that your family members can undergo multiple treatments within the coverage cap in a year. The limit resets annually. If the treatment costs exceed this limit, you will need to pay the additional expenses out of pocket. To avoid such scenarios, especially in the case of prolonged or high-cost illnesses, you can opt for a top-up plan from Bajaj General Insurance, which ensures your family is never left financially exposed.

*Standard T&C Apply

Disclaimer: The content on this page is generic and shared only for informational and explanatory purposes. It is based on several secondary sources on the internet and is subject to changes. Please consult an expert before making any related decisions.

Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.

Claims are subject to terms and conditions set forth under the health insurance policy.

The information presented is not meant to be a substitute for medical advice. Any suggestions mentioned should be considered for general use only. For expert guidance on any health ailment or medical issue or any treatment/procedure, please consult a certified medical professional.

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