Denied hospital refund despite husband’s Ayushman card, widow wins Rs 5.5 lakh

‘She underwent emotional trauma, harassment’

• The hospital was admittedly in possession of all treatment records, empanelment details, package information and Ayushman Scheme records.
• However, no documentary evidence has been produced to substantiate the plea of exclusion from the Scheme.

• The evidence on record reveals that during the treatment of her husband, the complainant was compelled to arrange substantial funds by borrowing from relatives and other sources. The patient unfortunately died soon after the treatment.
• The complainant not only suffered financial loss but also underwent immense mental agony, emotional trauma and harassment at a time when she was struggling to save the life of her husband.
• The conduct of the hospital has therefore caused substantial hardship to the complainant.
• CMO has produced the error and omission insurance policy and its terms and conditions.

Deceased treatment falls under ‘medical treatment’: Order

• The complainant has placed on record the Ayushman Bharat Card of the deceased along with the relevant Scheme documents.
• The said documents establish that the deceased was a beneficiary under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) and was entitled to receive cashless medical treatment in accordance with the Scheme guidelines.
• The principal defence of the hospital is that although it was empanelled under the Ayushman Bharat Scheme, its empanelment was restricted only to Cardiology and CardioThoracic Surgery, and therefore the treatment of the deceased was not covered under the Scheme.
• In support of its plea, the learned counsel for the hospital himself relied upon the Memorandum of Understanding (MOU) executed between MK Super Speciality Hospital Pvt Ltd, Rohtak and Ayushman Bharat Haryana Health Protection Authority.
• The commission has carefully examined the relevant clauses of the said MOU. Clause 13 defines “medical treatment” in broad terms and specifically provides that it includes diagnosis, treatment and management of illness, disease or injury, including medical management, symptom relief, prolongation of life and medical procedures.
• The MOU further reflects coverage of various diseases requiring hospitalisation and indoor treatment and does not confine the benefits only to cardiology procedures.
• The treatment received by the deceased squarely falls within the ambit of “Medical Treatment” as defined under Clause 13 of the MOU relied upon by the hospital itself.

Ayushman card holder denied refund by hospital

The complainant, the wife of the late man, filed a complaint against the Rohtak-based Positron Hospital for denying the benefit of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY).

She and her late husband were beneficiaries under the scheme, entitling him to free medical treatment up to Rs 5 lakh. On June 12, 2024, the complainant’s husband developed serious health issues, including stomach pain and acute breathlessness, and was initially taken to Bhiwani and thereafter admitted on June 13, 2024, in Positron Hospital at Rohtak.

According to the complaint, despite being covered under the Ayushman scheme,  she was illegally demanded and collected a huge amount of Rs 7.25 lakh on the false pretext that the amount would be refunded after approval under the scheme, whereas they were only entitled to receive the amount as per the scheme limit.

The complainant, under compulsion, arranged the amount by borrowing from relatives, and in the following days, the patient was discharged on June 25, 2024, without any improvement, and unfortunately died on June 26, 2024.

Thereafter, when the complainant demanded a refund of the excess amount of Rs 5 lakh, the hospital refused to refund and even stated that they do not provide treatment under the Ayushman scheme, where the Ayushman Bharat Haryana director and Chief Medical Officer (CMO) confirmed the entitlement of free treatment.

Complaint filed to extort money: Hospital

The hospital filed a written statement taking preliminary objections regarding maintainability, locus standi, suppression of true and material facts, absence of cause of action, misjoinder and non-joinder of necessary parties etc., and submitted that the present complaint is wholly misconceived, false, frivolous, vexatious, and an abuse of process of law, filed only to harass, defame and extort money from the answering the hopspital.

It was further pleaded that the complainant has not approached this Commission with clean hands and has deliberately concealed material facts and made false and misleading averments, hence is not entitled to any relief.

It is further averred that no deficiency in service, medical negligence, or unfair trade practice has been committed by the hospital, and the treatment was provided strictly as per standard medical protocol by competent and experienced doctors with due care and caution.

It was further submitted that at the time of admission, the attendants were clearly informed that the hospital was empanelled under the Ayushman Scheme only for specific specialities, i.e. Cardiology and Cardio-Thoracic Surgery, and since the patient was suffering from acute gastroenteritis with sepsis, the case was not covered under the said scheme, and the patient was admitted as a cash patient after due consent and understanding.

What is Ayushman Bharat Scheme?

The ambitious Ayushman Bharat or National Health Protection Scheme aims to cover over 10 crore vulnerable families (approximately 50 crore beneficiaries) and provide health cover up to Rs 5 lakh per family per year.

The programme is being touted as the world’s largest health protection scheme. The benefits of the scheme are portable across the country, and a beneficiary covered under the scheme will be allowed to take cashless benefits from any public/private empanelled hospitals across the country.

Significance of ruling

This judgment matters because it upholds the rights of Ayushman Bharat beneficiaries to receive cashless treatment. By penalising the hospital for illegal charging and unfair trade practices, it ensures that welfare schemes for the economically vulnerable are not undermined by hospitals withholding evidence of scheme exclusions.

Consumers facing similar grievances may contact the consumer helpline in their respective states (Haryana contact: 1800-180-2087) or dial the National Consumer Helpline at 1915 for assistance.