Quick answer: PM-JAY provides cashless hospital treatment up to ₹5 lakh per family per year, with no cap on family size or age, and pre-existing conditions covered from day one. It also covers 3 days of pre-hospitalisation and 15 days of post-hospitalisation expenses. It does not cover OPD consultations, standalone diagnostic tests, cosmetic procedures, or organ transplants.

Key Takeaways

• ₹5 lakh coverage is per family, per year — and it’s a floater, meaning any member can use any portion of it.
• Pre-existing diseases are covered from the very first day, with no waiting period, unlike most private health insurance.
• Coverage spans a wide range of hospitalization procedures across specialties including cardiology, oncology, orthopedics, and neurosurgery.
• OPD visits, routine diagnostics without hospitalization, and cosmetic or fertility treatments are excluded.

What’s Covered

Benefit	Details
Coverage amount	₹5 lakh per family per year, shared across all members
Pre-hospitalisation	3 days of related expenses before admission
Post-hospitalisation	15 days of related expenses after discharge
Pre-existing diseases	Covered from day one, no waiting period
Family size/age limits	None — no cap on number of members or their age
Payment model	Cashless and paperless at empanelled hospitals

What’s Not Covered

PM-JAY is a hospitalization scheme, not a general health-expense scheme. It generally excludes outpatient (OPD) consultations, standalone diagnostic tests done outside of a covered hospitalization, cosmetic procedures, fertility treatments, and organ transplants (though some states have separately added specific transplant packages). If you need routine checkups or day-to-day OPD care, an Ayushman Bharat Health & Wellness Centre near you is the better resource — that’s a separate, free primary-care service under the broader Ayushman Bharat program.

Multiple Surgeries in One Admission

If more than one surgical procedure is needed during a single hospital stay, PM-JAY pays the full package rate for the costliest procedure, then a reduced rate for each additional one — commonly around 50% for the second and 25% for the third, though exact rules can be revised by NHA from time to time, so it’s worth confirming current rates with the hospital’s PM-JAY desk for your specific case.

Pre- and Post-Hospitalization Expenses

PM-JAY doesn’t only cover the hospital stay itself. The scheme includes coverage for related expenses incurred shortly before admission (typically diagnostic tests and consultations in the days leading up to treatment) and for a defined follow-up period after discharge, such as medicines and check-ups tied directly to the treated condition. The exact number of covered days can vary by treatment package, so it’s worth confirming with your hospital’s Ayushman Mitra which pre- and post-hospitalization expenses apply to your specific procedure.

Frequently Asked Questions

How much coverage does PM-JAY provide?

Up to ₹5 lakh per family per year, shared as a floater among all family members with no cap on family size or age.

Are pre-existing diseases covered under PM-JAY?

Yes, pre-existing conditions are covered from day one with no waiting period, which is different from how most private health insurance policies work.

Does PM-JAY cover OPD consultations?

No, PM-JAY covers hospitalization-related expenses; routine OPD consultations and standalone diagnostic tests outside of a covered admission are excluded.

Does PM-JAY cover pre and post-hospitalisation expenses?

Yes, it covers 3 days of expenses before admission and 15 days of expenses after discharge, related to the treatment.

Does PM-JAY cover expenses before and after hospitalization?

Yes, PM-JAY includes coverage for certain pre-hospitalization diagnostics and post-discharge follow-up expenses tied to the treated condition, though the exact covered period varies by treatment package.

---

Related: Ayushman Bharat Treatment & Package List guide, Ayushman Bharat Health & Wellness Centres guide, and PM-JAY Hospital List guide.