How to claim maternity insurance for delivery in non-empanelled hospital?

Hello,

Under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), there is no provision for individual reimbursement if a child delivery or any other medical procedure is done at a non-empanelled hospital. The scheme is designed as a cashless treatment scheme, where beneficiaries normally receive covered treatment at an empanelled government or private hospital.

Why Can’t You Normally Claim the Amount Back?

• PM-JAY is not like a regular private health insurance policy where you pay the hospital first and later submit the bill for reimbursement.

• For regular PM-JAY benefits, the treatment must be taken at a hospital empanelled for the required service.

• The hospital also needs to have the applicable treatment package available.

• Therefore, if you voluntarily choose a non-empanelled hospital for delivery and pay the charges yourself, you should not expect those expenses to be reimbursed under regular PM-JAY.

• Hospital empanelment and the exact treatment package should always be confirmed before admission.

What If It Was a Genuine Emergency?

If the delivery was an emergency and the patient had to be taken to the nearest hospital, do not assume that the amount will automatically be reimbursed under PM-JAY.

Emergency provisions under PM-JAY have specific rules, and the standard PM-JAY process is designed around treatment through empanelled hospitals. Therefore, in an emergency case treated at a non-empanelled hospital, you should immediately contact the concerned State Health Agency or PM-JAY grievance/helpdesk and ask whether any exceptional provision applies in your state.

Keep all original documents and bills safely until you receive clarification.

For Further Treatment of Mother or Newborn

If the mother or newborn now needs additional treatment, it is better to check an empanelled hospital before admission.

A newborn can receive PM-JAY benefits subject to the applicable scheme conditions and available family benefit limit.

You can use the official PM-JAY hospital search to find an empanelled hospital and confirm the required treatment before admission.

Do not pay a large amount at a hospital assuming that you can later submit the bills under Ayushman Bharat. First confirm whether the hospital is empanelled and whether the required treatment is covered.

If you share your state and district, we can guide you on how to check the nearest empanelled hospital for the mother's or baby's further treatment.

Wishing you and your family good health always.
Warm regards,
Team HexaHealth