**Executive Summary**
The document is a response to an unstarred question in Lok Sabha regarding the standardisation of cost of life-saving surgeries. The response details government initiatives under Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) to reduce out-of-pocket health expenditure and standardize healthcare costs, and it mentions measures taken by IRDAI to make health insurance more accessible. The question was answered on December 12, 2025.
**Key Points / Main Content**
* **Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY):**
* Provides health cover of Rs. 5 lakh per family per year for secondary and tertiary care hospitalization for 12 crore families (bottom 40% of India's population).
* Uniform procedure rates are applicable across all empanelled hospitals; these rates are determined by expert committees.
* States and Union Territories have the flexibility to customize package rates.
* AB-PMJAY has reduced Out-of-Pocket Expenditure (OOPE), with savings over Rs. 1.25 lakh crore.
* Government Health Expenditure increased from 29% to 48% between FY 2014-15 and FY 2021-22, while Out-of-Pocket Expenditure declined from 62.6% to 39.4%.
* **Health Benefit Package (HBP) under AB-PMJAY:**
* Revised five times since the scheme's launch.
* HBP 2022 comprises 1,961 packages across 27 medical specialties (increased from 1,359 packages initially).
* 365 new treatment procedures added, and rates for 832 packages increased.
* Includes high-end procedures like bone marrow transplants and cochlear implant surgeries.
* Entire cost of treatment is covered; grievances regarding out-of-pocket payments are addressed.
* **Role of IRDAI:**
* Policyholders select the Sum Insured based on their requirements.
* Insurers assess and settle claims according to policy terms and conditions, subject to the Sum Insured.
* Extent of coverage depends on the Sum Insured, policy features, and surgery cost.
* IRDAI measures to improve access to health insurance:
* Insurers must empanel all categories of hospitals/health service providers considering affordability.
* Insurers must have a board-approved policy on quality standards for empanelment of Hospitals and Health Care Providers, providing 100% cashless services.
* **Clinical Establishments (Registration and Regulation) Act, 2010 (CE Act):**
* Provides for registration and regulation of Government and private clinical establishments.
* Requires clinical establishments to meet minimum standards and display rates.
* State Governments and Union Territories are responsible for regulating hospitals to ensure quality healthcare.
* Empowers registering authorities at the district level to take action, including penalties and cancellation of registration, for violations.
**Impact Analysis**
**Policyholders (Individuals with Health Insurance)**
* **Impact:** The actions taken by the IRDAI could lead to a wider range of hospital choices and the better affordability and availablity of health insurance.
* **Action Required:** Understand policy terms and conditions, especially relating to the Sum Insured.
**Empanelled Hospitals**
* **Impact:** Hospitals must adhere to the uniform procedure rates under AB-PMJAY and comply with quality standards set by insurers for empanelment.
* **Action Required:** Comply with the Clinical Establishments Act and display rates transparently.
**Beneficiaries under AB-PMJAY**
* **Impact:** The expanded Health Benefit Package offers more comprehensive coverage, potentially reducing out-of-pocket expenses.
* **Action Required:** Utilize the grievance redressal mechanisms for any issues related to out-of-pocket payments.
**State Governments and Union Territories**
* **Impact:** States and UTs are responsible for regulating hospitals and ensuring quality healthcare provision.
* **Action Required:** Enforce the Clinical Establishments Act within their jurisdiction.
**Insurers**
* **Impact:** Insurers are required to empanel hospitals considering the affordability of different population segments and follow IRDAI guidelines to provide quality cashless services.
* **Action Required:** Develop and implement board-approved policies on quality standards and benchmarks for empanelment.
Key Entities Referenced
Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY): A flagship health scheme providing health cover of Rs. 5 lakh per family per year for secondary and tertiary care hospitalization to economically vulnerable families in India.
Clinical Establishments (Registration and Regulation) Act, 2010 (CE Act): A law enacted by the Government of India to provide for the registration and regulation of clinical establishments.
Insurance Regulatory and Development Authority of India (IRDAI): The regulatory body that has taken measures to make health insurance products widely available and affordable.
Ministry of Health and Family Welfare: The primary government entity responsible for health and family welfare policies in India.
GOVERNMENTOFINDIA
MINISTRYOFHEALTH AND FAMILYWELFARE
DEPARTMENTOFHEALTH ANDFAMILYWELFARE
LOK SABHA
UNSTARREDQUESTION NO. 2123
TOBE ANSWERED ON12TH DECEMBER, 2025
STANDARDISATIONOFCOSTOFLIFE-SAVINGSURGERIES
2123. SHRIDUSHYANTSINGH:
Will the Minister of HEALTHAND FAMILYWELFAREbe pleased tostate:
(a) whether the Government proposes to examine and monitor the gap between the insured
amountandthe actual cost of surgeriesandthe consequent financial burdenon patients;
(b) if so, the details thereof along with the measures being considered by the Government to
reduce out-of-pocket health expenditure;
(c) whether any steps have been envisaged by the Government to standardize the cost of
surgeries,especially life-saving andessential surgeries, if so, the detailsthereof; and
(d) the details of the penal/regulatory provisions applicable to medical establishments that
compelpatientstomake upfront paymentsdespite havingvalidinsurance coverage?
ANSWER
THE MINISTER OFSTATEIN THE MINISTRYOFHEALTHAND
FAMILYWELFARE
(SHRIPRATAPRAOJADHAV)
(a) and (b): Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is a
flagship scheme of the Government which provides health cover of Rs. 5 lakh per family per
year for secondary and tertiary care hospitalization to 12 crore families constituting
economically vulnerable bottom 40% of India’s population. Under AB-PMJAY, uniform
procedure rates are applicable across all empanelled hospitals. These rates are determined by
expertcommittees.Additionally,StatesandUnionTerritorieshavebeengiventheflexibilityto
further customize the package rates. Economic Survey 2024-25 highlights AB-PMJAY’s
impact in reducing Out-of-Pocket Expenditure (OOPE) through increased social security and
primary health spending, with recorded savings over Rs. 1.25 lakh crore. Additionally,
between FY 2014-15 and FY 2021-22, Government Health Expenditure increased from 29%
to 48%, while Out-of-Pocket Expenditure has declined from 62.6% to 39.4%, as percentage
of Total HealthExpenditure.
As per the Insurance Regulatory and Development Authority of India (IRDAI) in respect of
health insurance policies, policyholders select the Sum Insured based on their requirements.At the time of claim, insurers assess and settle the claim in accordance with the terms and
conditionsof the policy, subject tothe Sum Insured available.As such, the extentof coverage
vis-a-vis the actual cost of treatment, depends on the Sum Insured, the specific policy
features opted by the customer and the surgery cost that varies from hospital to hospital.
IRDAI has taken the following measures to make the health insurance products widely
availableandaffordable for the customers.
(i) Insurersshallempanelallcategoriesofhospitals/healthserviceprovidersconsidering
the affordability of differentsegments of population.
(ii) Insurers shall have in place board approved policy on quality standards and
benchmarks for empanelment of Hospitals and Health Care Providers in order to
provide 100% cashless services to the policyholders. The said policy should enable
empanelment of all categories of hospitals considering the affordability of different
segments of population, and provide seamless journey to the policyholder at each
point of sale, service andclaim
(c)and(d): Under AB-PMJAY, the healthbenefit packageshave beenrevised five timessince
the launch of the scheme. Initially, the scheme included 1,359 packages, but Health Benefit
Package(HBP), 2022now comprises 1,961packages across 27 medicalspecialties. Atotalof
365 new treatment procedures have been added and the rates for 832 packages have been
increased. High end procedures such as bone marrow transplants and cochlear implant
surgerieshave beenintroduced,inadditiontothe alreadycovered kidneytransplants.
Under AB PM-JAY, the entire cost of treatment is covered under the HBP. Any grievance
received from beneficiaries regarding out-of-pocket or cash payments is addressed in
accordancewith the guidelines issued bythe National HealthAuthority.
Additionally, The Government of India has enacted the Clinical Establishments (Registration
and Regulation) Act, 2010 (CE Act) and notified the Clinical Establishments (Central
Government) Rules, 2012 (CE Rules) to provide for registration and regulation of
Government (except those of Armed Forces) as well as private clinical establishments
belonging to recognized systems of medicine. As per the CE Act, all the clinical
establishments (Government & private) are required to fulfill the conditions of minimum
standards of facilities and services, inter-alia, displaying of rates charged by them at a
conspicuous place. The State Governments and Union Territories administration which have
adopted the CE Act, are primarily responsible for regulating their hospitals including private
hospitals as per provisions of the Act and Rules thereunder to ensure the provision of quality
healthcaretopatients.
This Act has empowered to take action including imposing penalties against violation of its
provisions through a registering authority at the district level under the chairmanship of the
District Collector / District Magistrate. The Act also providesfor cancellation of registration,
iftheprovisionsoftheActarenotcompliedwith.
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