Mumbai: India’s flagship health insurance scheme, the Prime Minister Jan Arogya Yojana (PM-JAY), promises cashless treatment worth Rs 5 lakh a year for the country’s poorest. But in Mumbai, Thane, and Raigad, patients still face refusals, delays, and confusion.
Mixed Performance in Mumbai Region
In Mumbai, Thane, and Raigad districts, 28 hospitals 14 government and 14 private are currently empanelled under PM-JAY. A random telephonic check with some of these facilities revealed a mixed picture. Daytime responses were generally prompt, but evenings and late nights saw poor responsiveness. Some hospitals claimed the required treatment was unavailable and referred patients elsewhere, while a few did not respond at all.
Patient Experiences: Relief with Caveats
Alim Khan, a resident of Kurla, underwent heart surgery under PM-JAY. While the major cost was covered, he had to purchase some medicines from outside. “Ideally, the entire treatment should have been covered. I had no choice at the time but to buy medicines from the market,” Khan said, adding that he remained grateful for the substantial financial relief.
Hospital Hesitations and Reimbursement Delays
Reports indicate that certain empanelled hospitals deny cashless treatment to eligible patients or demand advance payments, citing low package rates or delays in reimbursement. In some cases, reimbursements take weeks or even months, discouraging private hospitals from active participation. Since health is a state subject, the quality of implementation varies widely — some states have robust systems, while others lag, creating disparities in outcomes.
The scheme offers cashless hospitalisation cover of up to Rs 5 lakh per family per year to over 50 crore low-income citizens. Designed as a safety net to shield the poorest from catastrophic medical expenses, it provides access to quality treatment in both public and private hospitals.
Recent Expansion for Senior Citizens
In 2024, the scheme was expanded to include all senior citizens aged 70 and above, irrespective of income. This move is expected to benefit around 4.5 crore families — including 6 crore senior citizens — with free health insurance of up to Rs 5 lakh per family.
However, the ground reality remains complex. “Many eligible households are unaware of their entitlement or how to use the scheme. Patients often visit hospitals without knowing how to claim the benefits,” said an official at Dr D Y Patil Hospital, Nerul. He stressed the need for greater public awareness and easy access to contact details of empanelled hospitals.
Awareness Gap and Misuse Risks
Hospital participation also remains uneven. Several private facilities have been reluctant to fully engage, arguing that the government-fixed package rates do not match actual treatment costs. Others point to reimbursement delays as a financial burden. Meanwhile, the scheme has also faced instances of misuse — including fraudulent claims, unnecessary admissions, and forged patient records.
Uneven Implementation Across States
Despite these challenges, PM-JAY continues to play a crucial role in expanding healthcare access for India’s most vulnerable citizens.
