Parliament Question: Rejection of Claims under AB-PMJAY

GOVERNMENTOFINDIA MINISTRYOFHEALTH AND FAMILYWELFARE DEPARTMENTOFHEALTH ANDFAMILYWELFARE LOK SABHA UNSTARREDQUESTION NO. 2241 TOBE ANSWERED ON 31STJULY, 2026 REJECTION OFCLAIMS UNDERAB-PMJAY 2241. DR. KALANIDHI VEERASWAMY: Will the Minister of HEALTHAND FAMILYWELFAREbe pleased tostate: (a) whether the Government has undertaken any assessment of the impact of rejected claims onbeneficiariesseeking timelymedicaltreatmentunderAB-PMJAY, if so,the detailsthereof; and (b) the measures taken by the Government to reduce claim rejection rates, strengthen grievance redressal mechanisms, improve transparency in claim processing and ensure that eligiblebeneficiaries receivetimelyhealthcare benefitsunderthe Scheme? ANSWER THE MINISTER OFSTATEIN THE MINISTRYOFHEALTHAND FAMILYWELFARE (SHRIPRATAPRAOJADHAV) (a) and (b): Under Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), all claims submitted by empanelled hospitals are adjudicated in accordance with Standard Treatment Guidelines, Health Benefit Package protocols, and the prescribed claims adjudicationmanual. Under the scheme, claim adjudication is continuously monitored by National Health Authority (NHA) through a robust IT-enabled Transaction Management System. Regular analysis of claim processing trends, including rejected claims, is undertaken to identify operational issues, improve claim adjudication quality, and facilitate corrective measures in coordinationwith the States/UTs. To ensure that eligible claims are not rejected without adequate scrutiny, a structured multi-level claim adjudication and review process is followed under AB-PMJAY. Before a claim is finally rejected, it is examined at multiple levels by designated medical and administrative authorities in accordance with the prescribed claim adjudication processes. In addition, a dedicated review committee has been established wherein empanelled hospitals may submit requests for review of rejected or partially paid claims within 15 days from the date of communication of the decision. Such requests are examined by a designated committeebefore arrivingat a final decision.Further, NHA regularly engages with States/UTs through review meetings, capacity-building initiatives, and monitoring mechanisms to improve the quality and timelines of claim processing. In cases of any irregularities in availing treatment by an empanelled hospital, beneficiaries can register their grievances through the Centralized Grievance Redressal Management System or the 24×7 toll-free helpline (14555), Ayushman App, and Ayushman Sarathi (WhatsApp chatbot). Under AB-PMJAY, such grievances are monitored through a three-tier grievance redressal mechanism at the District, State and National level. At each level, designated nodal officers and Grievance Redressal Committees are in place to examine and resolve the grievances, thereby strengthening accountability and facilitating effective implementation of the Scheme. *****