Ayushman Bharat – PM‑JAY is a flagship government health insurance scheme that provides cashless hospitalization coverage up to ₹5 lakh (per family per year) at empanelled public and private hospitals. It focuses mainly on hospitalization and critical care expenses. However, not everything is covered under the scheme. Understanding these exclusions can help beneficiaries plan better and avoid unexpected medical bills.

🏥 1. Outpatient (OPD) Treatments

Expenses for routine doctor visits, outpatient consultations, and medicines prescribed without hospital admission are not covered. This includes normal fever, cold, minor ailments, and consultations where no hospitalization is required.

🧪 2. Standalone Diagnostic Tests

Diagnostic tests such as blood tests, X‑rays, CT scans, MRIs, etc., that are done without hospitalisation, are excluded. They are only covered if they are part of a formal inpatient treatment plan.

🦷 3. Dental Treatments

Regular dental services are not covered under the scheme. These include treatments such as:

• Root canal treatment
• Cavity fillings
• Tooth extractions
• Dental implants
• Gum disease treatments

There’s an exception only if dental surgery is required due to an accident, tumour, cyst, or other medical condition that necessitates hospitalization.

🤰 4. Infertility & Fertility Treatments

The scheme generally does not cover IVF (in‑vitro fertilization) or other assisted reproductive procedures, surrogacy, or fertility‑related medical treatments unless specifically listed in the benefit package.

💉 5. Non‑Essential Vaccinations & Immunizations

Vaccines that are not part of the national immunization programme are excluded. This means routine preventive shots and private immunisations (like adult flu shots obtained privately) must be paid for by the patient.

💄 6. Cosmetic & Aesthetic Procedures

Cosmetic surgeries and beauty enhancement procedures are not covered unless they become medically necessary due to injury or disease. Examples of excluded procedures include:

• Liposuction
• Rhinoplasty
• Neck lifts
• Anti‑aging treatments
• Tattoo removal

These are considered elective or aesthetic, not medical essentials.

👶 7. Circumcision for Non‑Medical Reasons

Circumcision performed for religious or personal reasons is typically not covered unless it’s medically required due to illness or injury.

🧠 8. Persistent Vegetative State (PVS)

Medical care for patients in a persistent vegetative state—where a person is kept alive purely by life support without cognitive function—is excluded from Ayushman Yojana coverage.

🧘‍♂️ 9. Non‑Allopathic Treatments (Generally)

Treatments under alternative medicine systems such as Ayurveda, Homeopathy, Unani, and Siddha are usually not covered, unless specifically included as part of inpatient care under certain conditions.

🧠 10. Elective, Experimental or Unapproved Therapies

Any experimental, marginal, or unregistered medical treatments not recognised by the National health Benefit Package are excluded from coverage.

📌 Why These Exclusions Exist

Ayushman Bharat is designed mainly to:

✅ Protect families from catastrophic health expenditures
✅ Cover hospitalisation costs and major surgeries
✅ Reduce financial burden of serious illnesses

The exclusion of routine, outpatient, cosmetic, and non‑essential treatments helps ensure that the scheme’s funds are available for high‑cost, critical care needs.

🧾 Important Tips for Beneficiaries

✔ Always check whether a treatment requires hospitalisation to qualify for coverage.
✔ Ask the hospital’s Ayushman Mitra/Help Desk for clarification if unsure.
✔ Keep receipts and documents ready if seeking reimbursement or clarification.

 

Disclaimer:

The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any agency, organization, employer, or company. All information provided is for general informational purposes only. While every effort has been made to ensure accuracy, we make no representations or warranties of any kind, express or implied, about the completeness, reliability, or suitability of the information contained herein. Readers are advised to verify facts and seek professional advice where necessary. Any reliance placed on such information is strictly at the reader’s own risk.