A Golden Ticket to Nowhere

Ailing Wife In Rickshaw Van, 70-Yr-Old In Odisha Cycles 600km To Hospital & Back.¹

We are in a dimly lit, flickering fluorescent corridor in the Sahara Seva Hospital, a private hospital. It looks as if it created to be empanelled for Government schemes.

Dashrath is a 70-year-old man from Kakriguma, a village in Odisha. His hands are clutching a laminated Ayushman Bharat Card with the desperation of a man holding a winning lottery ticket in a burning building. He is rushing to respond to the summons by Ms Jia, a 30-year-old grumpy Patient Care Coordinator.

Jia herself is reeling with a double whammy this morning. Jia started her day with scolding by her mother-in-law at home for running off so early and later by her manager for being late for work. She has dark circles under her eyes due to lack of sleep, trying to be a supermom at home and an efficient working women in hospital. Her friends call her Counsellor for Impossible Situations. She has the privilege to announce to patient’s kins that hospital needs more money to continue patients’ treatment.

Dashrath has not had his breakfast, and his voice is trembling, “You are telling me that you need more money for treatment. But the card… the card says five lakhs. Why am I still asking for loans from the village moneylender?”

Picture as it was published with a news story in The New Indian Express on 25 January 2026

Jia sighed and leaned against a damp wall with peeling plaster, “Dashrath Mousa, that card is a work of art. It’s got the picture of the most powerful man in India, a gold border, and the promise of five lakh rupees. The only problem is that hospitals are unable to use this art as currency for buying antibiotics.”

Dashrath is a broken man, “Maa, we had initially gone to that Government Medical College and Hospital, but they said – No beds in ICU. But when I peeped through the window, I saw three empty beds in the ward!”

Jia wryly smiled and murmured to herself, “Yes those are the Quantum Beds, her physicists husband would say – unreal locally².”  Then louder she said, “You see, Mousa, in the Government Hospital, a bed only exists if there’s a budget to clean the bed-sheets. On paper, those beds are full of potential beneficiaries. In reality, Government hospitals always reserve some bed just in case a VIP may need it.  You were lucky. Usually, in government hospitals, the queue starts in the parking lot and ends in the afterlife.”    

Dashrath continued with his woes, “Then we went to that glass building—the MNC Chain Hospital. They saw my card, and the receptionist said they had retired from the scheme last month.    

Jia yawned and said dryly, “I know, doctors call it ‘Delayed Reimbursement Syndrome.”  The government owes that hospital Rupees twenty crores.  If they admitted your wife, they would have to pay for her medicine today, but the government will pay them back a small part of it next year.  And that’s only if the clerk doesn’t outright reject the claim because your thumbprint is 2% smudge and 98% ink. So, their scanner is permanently broken for people like you.”  

Dashrath continued, “Then, we came here; you all did take us in. You put Bidisa in the ICU. But now you say the ‘package’ does not cover the cost of treatment?”

Jia pointed to a chart in her hand, “This is the ‘Unspecified Surgical Package’ for her respiratory distress. It’s capped at one lakh rupees. That includes her bed, her oxygen, her medicines, her tests, and even my salary—which, by the way, I haven’t seen since the monsoon. Your wife has been in the ICU for five days. The “package” was made with presumption that patient should by cured or… well, “discharged”… in four days.”

Dashrath asked with raised eyebrows, “Cured in four days? Then why is she not cured? She can’t even breathe on her own!”

Jia seemed exasperated, “Unfortunately, the Ayushman rule book has not reached God. The package doesn’t care about her lungs; it cares about the “Average Length of Stay.” If she stays a fifth day, the hospital loses money. Every breath she takes now is a “financial non-viability.”  Yesterday, our manager told me that if she doesn’t get better by midnight, we have to “refer” her back to the Government Hospital—the one with the “No Beds.”  We call it the “Continuum of Care.” Most people call it a circle of hell.”    

Dashrath could not understand, “But I have five lakhs in the card! Use the rest of the four lakhs!”

Jia chuckled darkly, “Mousa, It doesn’t work like that. You have five lakhs “per family,” but you can only spend it in “pre-approved, bite-sized chunks.” Think of it like a food coupon that says ‘soft drinks’. You’re starving for food, but you will get “Soft drinks Only.” Her condition requires a ventilator, but our empanelled “ventilator package” doesn’t cover the specific high-end antibiotics she needs. And nor does it cover those diagnostic tests or CT scans! doctors are treating her blindly with a handicap as it is. Either we stop treating and wait for the inevitable, or you spend “out of pocket.”    

Dashrath relented, “But I already spent twenty thousand on those. I sold my wife’s silver jewellery. And they said the card is ‘cashless’.”

Jia sneered, “It is ‘cashless’ for the government because they aren’t paying us. It’s ‘cashless’ for you because you have no cash left. It is cashless for hospital as they will not get any cash from it. So it is cashless!.”   

Dashrath looked at the card and said, “They gave me this in a big ceremony at my village. There were photographs. The Sarpanch said we are “Atmanirbhar” now.”

Jia responded in the same vein, “ Ah, the ‘Photo-Op.’  It looks great on a billboard. “50 Crore Covered!”  It’s the ultimate sedative for us in the middle class. It gives us a feeling of safety as long as we do not fall sick. But once we land up in ICU, “coverage” does not translate into “care.” We’re “covered” by a paper shield in a thunderstorm. ”    

Dashrath was wiping a tear. “So what happens now?”

Jia was thoughtful for a moment, then said, “Now? I will go back inside and request our doctor to try to find a way to ‘unbundle’ her treatment. He will reluctantly do it as it amounts to cheating the system. He will finally modify his notes in such a way that I can file two different small claims instead of one big one. The big one will be rejected for sure but with two small ones, we do stand a chance. We calls it ‘creative documentation.” It’s the only way we can keep the lights on. If the doctor fails to innovate, Bidisa becomes another number in the “Out-of-Pocket Expenditure” column.  And you? You take your “Golden Ticket” and drive your rickshaw back to the village alone”.   

Dashrath broke down, “Maa, Will she live?

Jia looked away. Her own eyes were now wet, “Mousa, according to the official hospital statement, she is ‘Receiving Quality Tertiary Care in an Empanelled Facility.”  In the world of the “Photo-Ops,” she’s already a success story. In this corridor? She’s a budget failure. For us in the treating team, it is ultimate frustration – that we can’t give her treatment that we know may improve her.”   

Bidisa passed away two hours later, ending everyone’s misery. The cause of death was listed as “Respiratory Failure,” though Jia knew it was actually “Administrative failure.” Dashrath returned to his village, driving his rickshaw back, still clutching the card, now his only memento of a “cashless” journey that cost him everything.

The quest for a “Viksit Bharat” by 2047—a vision of a developed and inclusive nation—is fundamentally predicated on the health and resilience of its human capital. Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)³ is a flagship scheme that promises to provide free healthcare to the poor of India. Health, being a state subject, many states have modified it with different names.  It has done yeoman service to the poor by assuring free in-hospital treatment for several diseases. 

However, the rates of reimbursement are impractically low for treating many very sick patients, impacting the quality of treatment meted out to the poor. The scheme does not permit the hospitals to ask the patients to pay for any treatment. However, at times, when doctors see that the patient may die without treatment not covered in the scheme documents, they do cross the line. It happens often, because the Health Benefit Packages are unrealistic and do not include many special treatments routinely available in our country. The sarcasm in Jia’s statements is her inner anguish leaking out of her exhaustion after a sleepless night and morning’s turmoil.

The AB-PMJAY scheme controls expenditure through predefined package rates as well as an overall annual financial limit for each beneficiary family. A few examples of impractical rules are mentioned here:

(a) ICU expenditure is capped at 9350 without a ventilator and at 9900 with a ventilator (These are recently enhanced rates as per Health Benefit Package 2022).⁴  This bundle typically includes the cost of the procedure, room charges, nursing, surgeon/consultant fees, anaesthesia, blood, oxygen, and medicines for the duration of the stay, plus 15 days following discharge. A private Hospital in Bhubaneswar in real world, charges its cash-paying patients approximately 200000/- or more for a five-day ICU package. (It is a low estimate; in some high-end hospitals, the bill may be double or even higher). So if that hospital is empanelled, it will have to absorb the monetary loss somehow.

(b) At the scheme’s inception, 42% of health benefit packages were reimbursed at rates covering only half the actual cost of care.⁵

(c) Most recent high end cancer therapies are not included.⁶

(d) Outpatient care is covered for 15 days only after discharge from hospital, not before.⁷

(e) There is exclusion of several super speciality treatments and cross speciality encroachments.⁸ For example prophylactic endoscopic variceal ligation which is the standard of care for portal hypertension but is not covered in ABPMJAY. Only after bleeding has occurred, the endoscopic management of variceal bleed (code M14V2.16) is allowed at ₹50,000 for the episode (5-day package), but this package does not include treatment of other associated conditions such as ascites, sepsis and encephalopathy which often coexist. Absent cross speciality encroachment means that a patient admitted for lung disease can not get dialysis done if it is required.

Several high-end hospitals do not seek empanelment with the PMJAY scheme because of these reasons. While it is definitely a boon for several procedures that are selectively covered with adequate compensation, most doctors know that in managing very sick patients, ABPMJAY is nothing more than a golden ticket to nowhere. If political mandate was to help the masses, the persons who have framed the rules to utilise it, have done gross injustice to the original intention.

Notes:

1. The picture shown above was published in the New India Express⁹ about a man, Lohar, who brought his wife for treatment to a Government medical College and went back after her success treatment. This blog is not about him. It is about scores of other poor patients whose plight is never told.
2. The names of various characters, places as well as hospitals in the above anecdote, are imaginary, but this conversation and the frustrating counselling of poor patients is a routine fare in most hospitals almost everyday

References

1. https://timesofindia.indiatimes.com/india/ailing-wife-in-rickshaw-van-70-yr-old-in-odisha-cycles-600km-to-hospital-back/articleshow/127427716.cms accessed on 17 Feb 2026 ↩︎
2. https://azimpremjiuniversity.edu.in/faculty-research/is-the-universe-unreal-as-per-quantum-mechanics accessed on 17 Feb 2026 ↩︎
3. https://beneficiary.nha.gov.in/ accessed 17 Feb 2026 ↩︎
4. Kaur, A., Jayashree, M., Prinja, S. et al. Cost analysis of pediatric intensive care: a low-middle income country perspective. BMC Health Serv Res 21, 168 (2021). https://doi.org/10.1186/s12913-021-06166-0 ↩︎
5. Jyani G, Gedam P, Sharma S, Dixit J, Prinja S. Financial Viability of Private Hospitals Operating Under India’s National Health Insurance Scheme Ayushman Bharat Pradhan Mantri-Jan Arogya Yojana (AB PM-JAY). Appl Health Econ Health Policy. 2025 Sep;23(5):841-853. doi: 10.1007/s40258-025-00966-9. Epub 2025 Apr 11. PMID: 40216706; PMCID: PMC12364732. ↩︎
6. https://www.carercircle.com/editorial/article/3680/ayushman-bharat-coverage-for-cancer-explained accessed on 17 Feb 2026 ↩︎
7. https://accountabilityindia.in/blog/as-the-pradhan-mantri-jan-arogya-yojana-evolves-some-challenges-remain-rooted/ accessed on 17 Feb 2026 ↩︎
8. Kadam D. Plastic Surgery Specialties in Ayushman Bharat Yojana: The Gaping Concerns. Indian J Plast Surg. 2020 Mar;53(1):1-3. doi: 10.1055/s-0040-1710144. Epub 2020 Apr 25. PMID: 32367909; PMCID: PMC7192654. ↩︎
9. https://www.newindianexpress.com/topic/man-cycles-350-km-for-wifes-treatment ↩︎