Ayushman Bharat: Key health conditions not covered under ₹5 lakh insurance

Ayushman Bharat (AB PM-JAY) excludes OPD care, dental work, IVF, and cosmetic surgery from its ₹5 lakh health insurance cover - here's the full list of uncovered conditions

Delhi has recently become the 35th state or union territory to implement the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY). If you are among the millions relying on the government-backed health insurance scheme for hospital treatment, it is important to know what is not covered. Being aware of exclusions can help you avoid last-minute financial surprises during medical emergencies.

 

While the scheme offers an annual health cover of ₹5 lakh per family that is economically vulnerable — and to all senior citizens aged 70 and above, irrespective of income or socio-economic status — for secondary and tertiary hospitalisation, here’s what Ayushman Bharat, launched on September 23, 2018, does not include.

Diseases and treatments not covered under Ayushman Bharat

According to the latest National Health Benefit Package guidelines issued by the National Health Authority (NHA), AB-PMJAY is not liable to pay for the following:

 

Outpatient treatments (OPD): Conditions that do not require hospitalisation, such as regular doctor consultations, diagnostics, and routine medication, are excluded.

 

Evaluation-only hospital stays: Expenditures during hospitalisation meant solely for evaluation or diagnostics, and expenses on vitamins, tonics, or supplements, unless prescribed as part of a certified treatment plan.

 

Dental treatments: Corrective, cosmetic or prosthetic dental procedures, root canals, cavity fillings, dental implants, and treatment for periodontal diseases are excluded.

 

• Exception: Dental treatment arising from trauma, tumours, or cysts requiring bone treatment and hospitalisation is covered.

 

Infertility treatments: IVF and other assisted reproductive technologies are not covered unless specifically listed in the National Health Benefit Package.

 

Non-essential vaccinations and immunisations: Any immunisation that is not part of a national programme.

 

Cosmetic surgeries: Treatments purely for aesthetic reasons, such as anti-ageing procedures, laser tattoo removal, rhinoplasty, fat grafting, neck lifts, and similar surgeries.

 

Circumcision (for children under 2): Excluded unless required for medical treatment of an unrelated condition or resulting from an accident.

 

Persistent vegetative state cases: Where a patient is kept alive by machines and shows no cognitive or physical response, coverage is not provided.

 

Why are these conditions excluded?

The Ministry of Health and Family Welfare (MoHFW) explains that Ayushman Bharat is designed to target catastrophic health expenses — critical conditions requiring hospitalisation and intensive care. Excluding routine, cosmetic, or elective procedures helps ensure that the scheme remains focused, sustainable, and impactful for the largest segment of the population.

 

What to do if your treatment isn’t covered?

Here are some steps you can take when facing a procedure that’s not included in AB PM-JAY:

 

• Check eligibility and hospital status on the official Ayushman Bharat portal.
• Consult your doctor to confirm if the procedure qualifies under the scheme.
• Plan ahead by saving for uncovered expenses or purchasing a supplementary health insurance policy.

What’s covered under the scheme?

According to the MoHFW, specialties covered under AB-PM-JAY include: 

• Burns management
• Cardiology and cardiothoracic surgery
• Emergency room packages (for care under 12 hours)
• General medicine and surgery
• Interventional neuroradiology
• Medical and surgical oncology
• Mental health treatment
• Neonatal care
• Neurosurgery
• Obstetrics and gynaecology
• Ophthalmology
• Oral and maxillofacial surgery
• Orthopaedics
• Otorhinolaryngology (ENT)
• Paediatric medicine and surgery
• Plastic and reconstructive surgery
• Polytrauma care
• Radiation oncology
• Urology
• Paediatric cancer treatment 

How to avail the benefit under Ayushman Bharat

Eligible individuals can access benefits by downloading an e-card from the official website https://pmjay.gov.in.

 

Documents required to apply:

• Aadhaar card
• Identity proof (driving licence, passport, or voter ID)
• Residential proof (utility bill, passport, or voter ID)
• Family details (names and Aadhaar numbers)
• Caste certificate (if applicable)
• Income certificate
• Bank account details 

 

Steps to apply on the portal:

• Enter your mobile number and fill in the captcha
• Verify with the OTP received
• Select your state
• Check eligibility using your ration card number or other accepted documents
• If eligible, your name will appear. Click on the ‘family members’ section to view other household beneficiaries

 

Once verified, you can download your PM-JAY e-card via:

• NHA Beneficiary portal
• Ayushman app
• Umang portal
• DigiLocker

You can then use the e-card to access cashless health services at empanelled public and private hospitals under the scheme.   For further assistance, you can contact the Ayushman Bharat helpline at 14555 or visit the official website: https://pmjay.gov.in   For more health updates and wellness insights, follow #HealthWithBS