A new study commissioned by NITI Aayog has revealed that many patients under the government’s health insurance scheme still spend a significant amount of money during hospital treatment.
According to the study, patients using private hospitals under Pradhan Mantri Jan Arogya Yojana spend an average of ₹53,965 from their own pockets for each hospitalisation.
This money is mainly spent on medicines, transport, and diagnostic tests.
The evaluation was carried out by IQVIA and submitted to the Development Monitoring and Evaluation Office of NITI Aayog.
Study Examined Thousands of Households
Researchers surveyed 2,283 households across 13 states and Union Territories to understand how healthcare schemes are working on the ground.
Out of these households:
1,489 households (65%) had health insurance
794 households (35%) had no insurance
Among those with insurance, most were covered by government schemes.
About 1,156 households were beneficiaries of PMJAY, while a small number had private health insurance.
The survey also found that 1,201 individuals had been hospitalised in the past five years, which represented around 23% of the people studied.
Many PMJAY Patients Still Paying Out of Pocket
One of the key findings of the report was that many beneficiaries still have to pay expenses themselves.
Around 35% of PMJAY patients said they did not spend any extra money during hospital treatment.
However, 65% reported paying out-of-pocket expenses, mainly for medicines, travel to hospitals, and diagnostic services.
Patients treated in private hospitals spent an average of ₹53,965 per hospitalisation, while those using public hospitals spent around ₹21,827.
This shows that treatment in private facilities can be much more expensive even under the government scheme.
Costs in Private Hospitals Are Much Higher
The study also compared expenses between insured and uninsured patients.
On average:
Insured patients spent ₹34,790 per hospitalisation
Uninsured patients spent ₹38,084
This means PMJAY beneficiaries spent about ₹3,294 less than people without insurance, but the difference was not very large.
The biggest gap appeared in private hospitals.
Uninsured patients spent an average of ₹74,847 per hospitalisation in private hospitals, compared with ₹11,146 in public hospitals.
Researchers noted that even though the scheme covers many medical services, some costs such as transport and certain medicines or diagnostic tests are not fully covered.
About the PMJAY Health Scheme
The Ayushman Bharat initiative launched PMJAY on September 23, 2018 to provide affordable healthcare to millions of Indians.
Under the scheme, eligible families can receive health coverage of up to ₹5 lakh per year for secondary and tertiary medical treatments.
The program targets more than 12 crore families, which equals around 55 crore people across India.
It covers 1,961 medical procedures across 27 specialities.
In September 2024, the government expanded eligibility to include all citizens aged 70 years and above, regardless of income.
Despite the wide coverage, the study suggests that reducing out-of-pocket expenses, especially in private hospitals, remains an important challenge for the scheme.
