Comprehensive Guide to PM Health Insurance: Coverage, Benefits, and How to Apply

In India, many coming from the economically weaker section cannot afford the heavy medical bills. Standards hospital charges may start at ₹25,000 just for a three-day admission for a fever. Surgeries often start at ₹1.5 lakhs minimum. 

Families with limited earnings per month can’t cover these costs without taking out loans or selling assets. PM Health Insurance, Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana, addresses this exact problem. 

Let’s walk through in detail about how this scheme works, the annual coverage, its benefits, and the application process.

About PM Health Insurance

PM Health Insurance gives ₹5 lakh coverage per family every year. This amount covers your entire household, not each person separately. A family of three gets ₹5 lakhs total. A family of nine also gets ₹5 lakhs total. Family size doesn’t change the coverage amount. The limit resets every policy year.

PM Health Insurance can include up to 1,949 different medical procedures across 27 medical specialties. This covers the most serious treatments people actually need, for example:

• Major surgeries, including bypass operations, knee replacements, and brain surgeries
• Cancer treatments like chemotherapy and radiation therapy
• Cardiac procedures such as angioplasty and valve replacements
• Pre-hospitalisation expenses 
• Post-hospitalisation costs
• Follow-up medicines, tests, and doctor visits related to your treatment
• General ward room charges are fully covered
• Semi-private or private rooms covered up to approved package rates
• Newborn coverage from birth if parents are enrolled

Benefits for Common People

PM Health Insurance benefits the common people as follows:

No More Medical Debt

A heart surgery costing ₹2.5 lakhs or cancer treatment running ₹4 lakhs doesn’t push families into poverty. The scheme handles these bills completely.

Cashless Treatment Process

Walk into an empanelled hospital, show your Aadhaar or scheme card, and get admitted. No advance deposits. No payment at discharge. The hospital settles everything with the scheme authorities later.

Completely Free Coverage

PM Health Insurance comes absolutely free. No annual fees, no registration charges, no hidden costs anywhere in the process. You never pay a single rupee for maintaining this coverage.

Works Across All States

Coverage works nationwide, not just in your home state. A migrant construction worker from Odisha working in Gujarat can get treated at any empanelled Gujarat hospital using the same coverage.

Immediate Disease Coverage

Pre-existing conditions don’t have waiting periods. Private insurance makes you wait 2-4 years before covering diabetes complications or hypertension-related issues. This scheme covers them from day one.

Same Coverage Regardless of Family Size

Three members or ten members, coverage stays at ₹5 lakhs for the family. Private insurance charges per person, making large families expensive to cover. Here, family size creates no limitations.

No Age Restrictions

Elderly parents above 65 or 70 get the same coverage. Private insurance either rejects senior citizens or charges premiums so high that they become unaffordable. Age doesn’t matter under this scheme.

Eligibility Criteria for PM Health Insurance

Eligibility for the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana is mainly based on socio-economic conditions. The government identifies beneficiaries using data from the Socio-Economic Caste Census (SECC) 2011. Families that fall under certain deprivation categories in rural areas or specific occupational groups in urban areas can receive coverage under the scheme.

Eligibility Requirements for Rural Beneficiaries

In rural areas, households are eligible if they fall under at least one of the following deprivation categories:

• Only one room with kucha walls and a kucha roof
• No adult member aged 16–59 years
• No adult male member aged 16–59 years
• Disabled member with no able-bodied adult in the household
• SC/ST households
• Landless households earning most of their income from manual casual labour

Automatic inclusion categories:

• Households without shelter
• Destitute people or those living on alms
• Manual scavenger families
• Primitive tribal groups
• Legally released bonded labourers

Eligibility Requirements for Urban Beneficiaries

In urban areas, eligibility is based mainly on occupation. Families belonging to the following worker categories can qualify:

• Ragpickers
• Beggars
• Domestic workers
• Street vendors, cobblers, hawkers, and other street service providers
• Construction workers, plumbers, masons, labourers, painters, welders, security guards, coolies, and head-load workers
• Sweepers, sanitation workers, and gardeners (mali)
• Home-based workers, artisans, handicraft workers, and tailors
• Transport workers such as drivers, conductors, helpers, cart pullers, and rickshaw pullers
• Shop workers, assistants, peons in small establishments, delivery assistants, attendants, and waiters
• Electricians, mechanics, assemblers, and repair workers
• Washermen and chowkidars

Common Exclusions

Some households are not eligible for the scheme if they fall into certain economic categories. These include families who:

• Own two-, three-, or four-wheelers or a motorised fishing boat
• Own mechanised farming equipment
• Hold Kisan Credit Cards with a limit of ₹50,000 or more
• Are government employees
• Work in government-managed non-agricultural enterprises
• Earn more than ₹10,000 per month
• Own a refrigerator or landline phone
• Live in solid, well-built houses
• Own 5 acres or more of agricultural land

How to Apply for PM Health Insurance

Follow the steps below while applying to PM Health Insurance. The process varies slightly depending on whether you’re already listed or need to be added.

Step-by-Step Process to Apply Online

Follow these steps:

Step 1: Register on the UMANG Portal

Visit the official website of UMANG. Click “Register” at the top-right corner of the homepage. This will open the registration page.

Step 2: Verify Mobile Number and Create MPIN

Enter your mobile number on the verification page. Verify it using the OTP sent to your phone. Create an MPIN to complete registration. Log in using your mobile number and MPIN.

Step 3: Access Services

After login, go to the “All Services” tab. Choose the service you want to apply for. The online application form will open.

Step 4: Fill the Application Form

Enter all required details in the form. Enter all required details in the form. Check all the information and the uploaded documents carefully. Make corrections if needed. Accept the terms, declaration, and privacy policy.

Step 5: Submit the Application

Click “Submit” or “Apply.” You will receive a confirmation message after successful submission.

Step-by-Step Process to Apply Offline

If you want to apply offline, you can follow these steps:

Step 1: Submit Basic Details

Visit the nearest Ayushman centre or hospital help desk. Provide details such as PM letter, RSBY URN, ration card number, or mobile number. The Arogya Mitra searches your name in the beneficiary list.

Step 2: Search in the System

The operator searches your details in the BIS application database. This includes SECC, RSBY, state health schemes, and other beneficiary databases.

Step 3: Individual Identification

If your name appears, your identity must be verified. If your name appears, your identity must be verified. Provide a ration card or family ID for verification. The operator scans and uploads these documents.

Step 4: Family Verification

The Arogya Mitra verifies your family details using the ration card. Family records are checked, and scanned documents are uploaded. The details are sent to the insurance company or trust for review.

Step 5: Approval or Rejection

The insurance company or trust reviews the application. They may approve or recommend rejection. The State Health Agency (SHA) makes the final decision if needed.

Step 6: E-Card Issuance

Once approved, an Ayushman e-card is issued. This card allows you to access cashless treatment under the scheme.

Using Coverage for Treatment

Check if your chosen hospital is on the approved hospital list. The official website lists all participating hospitals, searchable by city or district. Most government hospitals and many private hospitals participate.

Inform the admission desk that you’re an Ayushman beneficiary. Give your scheme card or Aadhaar number. The hospital’s Ayushman Mitra desk verifies eligibility in their system. It takes just a few minutes. Once confirmed, your hospitalisation record gets created.

Treatment proceeds normally after verification. Doctors conduct necessary tests, surgeries, or procedures. You receive appropriate care based on medical requirements. Get your discharge summary before leaving. It lists all treatments, medicines, and procedures done. You’ll need this for records and any follow-up care.

Collect post-discharge medicines from the hospital pharmacy. Up to 15 days’ worth of required medicines are included in the package.

How Claims Work

Hospitals handle everything. You don’t file claims yourself. This removes complicated paperwork. After treatment, hospitals submit claims online through the government’s Transaction Management System. They upload discharge papers, treatment records, bills, and test reports.

State authorities review submitted claims. They verify treatments fall under covered packages and charges match approved rates. Payment typically happens within 15-30 days. Money goes directly from the scheme to the hospital.

Common Issues and Their Solutions

Below are the common issues many people face during the PM Health Insurance process. Check out their solution also:

• Verification keeps failing? This sometimes happens due to system glitches. Try again after a few minutes. If the automated system still doesn’t work, reach out to your state helpline. They can verify your details manually.
• Hospital denying treatment or asking for unauthorised payments? Call 14555 right away. You can also contact district-level Ayushman officers who handle these complaints.
• Can’t find your name on the beneficiary list? If you meet the eligibility criteria but aren’t listed, visit your district health officer with proof of your eligibility. They’ll start the process to add you.
• Hospital charging too much for covered procedures? Treatment packages have fixed rates across all empanelled hospitals. If one hospital quotes inflated prices for a procedure that’s covered, simply switch to another approved hospital where standard rates apply.

Conclusion

PM Health Insurance provides free healthcare worth ₹5 Lacs/Annum to the families that need it the most. You are not going to pay a single rupee for treatment at any of the thousands of hospitals throughout the country.

Find out whether you’re eligible online or at a local health centre. Once you confirm your eligibility, put every family member on the list. Carry your Ayushman card or Aadhaar with you and check which local hospitals are covered under the scheme.

In the case of a medical emergency, knowing how this all works can save you a lot of grief. You’ll have enough health problems to worry about. This insurance takes the cost off your mind so you can focus on getting better, rather than worrying about paying. Treatment should not be based on what you can afford, but on what you medically need.