Ayushman Bharat Scheme: List of Medical Treatments Not Covered

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), launched in 2018, is one of India’s largest publicly funded healthcare insurance schemes. Aimed at providing financial protection to the economically vulnerable, it offers an annual health cover of ₹5 lakh per family for secondary and tertiary hospitalisation. With Delhi recently becoming the 35th state or union territory to implement this scheme, millions of citizens are now eligible for its benefits.

However, while this scheme brings a safety net to many, it is crucial to understand that not all medical conditions and procedures are covered. This article highlights the key health exclusions under Ayushman Bharat so that individuals can make informed decisions and avoid unexpected expenses during medical emergencies.

Conditions Not Covered Under Ayushman Bharat

As per the latest National Health Benefit Package guidelines issued by the National Health Authority (NHA), certain diseases and treatments fall outside the coverage of AB-PMJAY.

Outpatient Treatments (OPD)

Conditions that do not require hospital admission — such as routine doctor consultations, diagnostic tests, and medications for chronic illnesses — are not included in the scheme.

Hospitalisation for Evaluation Only

If a hospital stay is solely for observation or diagnostic purposes, the expenses incurred are not covered. Similarly, vitamins, supplements, or tonics are excluded unless they are part of a certified treatment plan.

Dental Treatments

Procedures like root canals, cavity fillings, implants, or treatment for gum diseases are excluded from coverage.

Exception:
Dental treatments necessitated by trauma, cysts, or tumours that require hospitalisation and surgical intervention are included.

Infertility Treatments

Procedures such as IVF or other assisted reproductive technologies are not covered unless specifically mentioned in the benefit package.

Non-Essential Vaccinations and Immunisations

Vaccines not listed under national immunisation programmes are excluded.

Cosmetic Surgeries

Surgeries performed for aesthetic improvement — including tattoo removal, rhinoplasty, anti-ageing procedures, and neck lifts — are not covered under the scheme.

Circumcision for Infants Under Two

Circumcision is excluded unless medically necessary due to unrelated illness or accident.

Persistent Vegetative State

Patients who are kept alive by life-support machines without cognitive or physical responsiveness are not eligible for coverage.

Why These Exclusions Exist

According to the Ministry of Health and Family Welfare (MoHFW), the primary aim of Ayushman Bharat is to protect individuals from catastrophic health expenditure. By focusing on life-threatening and financially draining conditions that require hospitalisation, the scheme ensures better sustainability and wider outreach. Excluding elective, cosmetic, and routine procedures allows the programme to channel its resources more effectively to those most in need.

What to Do If Your Treatment Isn’t Covered

If you or a family member requires a procedure not listed under AB-PMJAY, you can take the following steps:

• Verify hospital empanelment on the official Ayushman Bharat portal.
• Seek medical advice to confirm if the treatment may qualify under any covered package.
• Plan for uncovered expenses by setting aside emergency funds or investing in additional health insurance plans that can complement Ayushman Bharat.

What’s Covered Under Ayushman Bharat?

While certain exclusions exist, Ayushman Bharat covers a wide array of specialities and treatments, including:

• Burns management
• Cardiology and cardiothoracic surgery
• Emergency care (under 12 hours)
• General medicine and surgery
• Interventional neuroradiology
• Oncology (medical, surgical, radiation)
• Mental health care
• Neonatal and paediatric care
• Neurosurgery
• Obstetrics and gynaecology
• ENT (Otorhinolaryngology)
• Oral and maxillofacial surgery
• Orthopaedics
• Urology
• Plastic and reconstructive surgery
• Polytrauma management

These inclusions aim to ensure critical and often expensive hospital treatments are within reach of economically disadvantaged families.

Conclusion

Ayushman Bharat is a landmark healthcare initiative that has brought financial relief to millions. However, understanding its exclusions is equally important. Being aware of what the scheme does not cover allows individuals to prepare better for their healthcare needs and make decisions with clarity, avoiding financial strain during emergencies.

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