Ayushman Bharat PM-JAY Health Insurance in West Bengal

Source: Pradhan Mantri Jan Arogya Yojana (PM-JAY), 2018 — Central Government Scheme; Ayushman Bharat — Health and Wellness Centres (AB-HWC)

Reviewed by the Commoner Law Editorial Team. Sourced from Indian central (Union) law — Constitution of India, central Acts of Parliament, and Supreme Court decisions. State-level information reflects each state's own Acts and High Court rulings. Written in plain language for general understanding — this is educational content, not legal advice. Our editorial standards

Indian Central Law

What is this right?

PM-JAY is the world's largest publicly funded health insurance scheme, providing coverage of up to ₹5 lakh per family per year for secondary and tertiary hospitalisation.

Eligibility: Approximately 12 crore families (about 55 crore individuals) identified based on the Socio-Economic Caste Census (SECC), 2011 — primarily BPL families, rural families in specified occupational categories, and urban families in specified categories.
Coverage: Up to ₹5 lakh per family per year (family-floater basis) for hospitalisation — covers surgery, medicines, diagnostics, ICU charges, and follow-up for 15 days.
Over 27 specialties: Covers cardiology, oncology, neurosurgery, orthopaedics, nephrology (including dialysis), and more — over 1,900 defined medical procedures and packages.
Cashless treatment: Treatment is cashless at empanelled public and private hospitals (over 28,000 empanelled hospitals across India). The patient pays nothing at the point of care.
Portability: A beneficiary can use PM-JAY at any empanelled hospital anywhere in India — the scheme is portable across states.
How to check eligibility: Visit pmjay.gov.in, enter your name and mobile number or Ration Card number to check if you are a beneficiary.

When does it apply?

You are from a family identified under the SECC database and require hospitalisation for surgery or serious illness.
You want to check whether you are eligible for PM-JAY coverage.
A hospital is refusing to admit you on PM-JAY or demanding cash payment for a covered procedure.

What to Do If an Empanelled Hospital in India Refuses to Accept Your PM-JAY Coverage

Check eligibility at pmjay.gov.in or the PM-JAY helpline: 14555.
At the hospital, show your Ayushman Card (printable from the PM-JAY portal after e-KYC) at the hospital's PM-JAY desk — the hospital must register and treat you cashlessly.
If an empanelled hospital refuses PM-JAY or demands extra payment beyond the package rate, call the PM-JAY helpline 14555 — fraudulent hospitals can be de-empanelled.
Generate your Ayushman Card in advance (before hospitalisation) at any Common Service Centre (CSC) using your Aadhaar and mobile number.

What should you NOT do?

Do not pay cash to empanelled hospitals for procedures covered under PM-JAY — the treatment is meant to be cashless. Report any demand for out-of-pocket payment for covered procedures.
Do not allow hospitals to falsify your PM-JAY claim (billing for procedures not performed) — PM-JAY fraud affects the entire scheme; report suspected fraud to 14555.
Do not miss the 15-day post-discharge follow-up coverage — medicines and consultations related to the same episode of illness within 15 days of discharge are covered.

West Bengal Law

How West Bengal differs from central law

West Bengal has not joined the central government's Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY). The state government chose to implement its own health insurance scheme — Swasthya Sathi — arguing that it provides broader coverage than PM-JAY. Unlike PM-JAY, which is targeted at families identified through the SECC database, Swasthya Sathi covers all families in West Bengal regardless of income or socio-economic status.

Swasthya Sathi provides annual coverage of up to Rs. 5 lakh per family for secondary and tertiary hospitalization at government and empanelled private hospitals. The scheme covers pre-hospitalization expenses (up to 15 days before) and post-hospitalization expenses (up to 90 days after). The smart card is issued in the name of the woman head of the family, a deliberate policy to empower women.

Because West Bengal is not part of PM-JAY, residents cannot use Ayushman Bharat cards for treatment in other states, and residents of other states cannot use their PM-JAY cards in West Bengal. This has been a subject of political debate, but the state government has maintained its separate scheme.

Additional Steps in West Bengal

Enroll in Swasthya Sathi at your nearest Duare Sarkar camp or Block Development Office. Carry your Aadhaar card and ration card. The smart card is issued in the woman head of household's name. To find empanelled hospitals, contact the Swasthya Sathi helpline or check with the District Health Office. If you travel to another state for treatment, be aware that Swasthya Sathi may not cover treatment outside West Bengal — check with the scheme administrator before traveling.

Relevant Law: Swasthya Sathi Scheme, Government of West Bengal, Health and Family Welfare Department (Government Order No. HF/O/SATHI/40/2016 and subsequent amendments)

Common Questions

When does ayushman bharat pm-jay health insurance apply?

You are from a family identified under the SECC database and require hospitalisation for surgery or serious illness.You want to check whether you are eligible for PM-JAY coverage.A hospital is refusing to admit you on PM-JAY or demanding cash payment for a covered procedure.

What should I do if a hospital is refusing to treat me under Ayushman Bharat PM-JAY or demanding cash payment in India?

Check eligibility at pmjay.gov.in or the PM-JAY helpline: 14555.At the hospital, show your Ayushman Card (printable from the PM-JAY portal after e-KYC) at the hospital's PM-JAY desk — the hospital must register and treat you cashlessly.If an empanelled hospital refuses PM-JAY or demands extra payment beyond the package rate, call the PM-JAY helpline 14555 — fraudulent hospitals can be de-empanelled.Generate your Ayushman Card in advance (before hospitalisation) at any Common Service Centre (CSC) using your Aadhaar and mobile number.

What mistakes should I avoid with ayushman bharat pm-jay health insurance?

Do not pay cash to empanelled hospitals for procedures covered under PM-JAY — the treatment is meant to be cashless. Report any demand for out-of-pocket payment for covered procedures.Do not allow hospitals to falsify your PM-JAY claim (billing for procedures not performed) — PM-JAY fraud affects the entire scheme; report suspected fraud to 14555.Do not miss the 15-day post-discharge follow-up coverage — medicines and consultations related to the same episode of illness within 15 days of discharge are covered.

Ayushman Bharat PM-JAY Health Insurance in other states

Same topic, different jurisdiction. Pick the one that applies to you.