In a significant move to counter fraudulent activities in the health insurance sector, the Centre has rejected a substantial 3.56 lakh fraudulent health insurance claims, amounting to Rs 643 crore, under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). This decision, announced by Union Minister of State for Health Prataprao Jadhav, also includes the de-empanelment of 1,114 hospitals, penalising 1,504 hospitals with fines totalling Rs 122 crore and suspending 549 hospitals.
The AB-PMJAY has adopted several measures to enhance transparency and reduce fraudulent claims. Jadhav told Rajya Sabha that a robust anti-fraud mechanism has been established, including the National Anti-Fraud Unit, tasked with the prevention, detection, and deterrence of misuse. The scheme operates under a zero-tolerance policy towards any form of abuse. To ensure only genuine claims are processed, technologies like near real-time monitoring and AI-based systems are employed. Furthermore, beneficiaries are verified using Aadhaar e-KYC during card creation and again at service availing, minimising the chances of duplicate or fraudulent claims.
Under this scheme, various triggers in the Transaction Management System alert authorities to suspicious activities such as upcoding of health benefit packages, conversion of outpatient procedures to inpatient ones, and ghost billing—where treatment is billed but not rendered. These automated flags prompt investigations into suspected claims, helping maintain the scheme's efficacy. According to Jadhav, random audits and surprise inspections of hospitals further ensure the authenticity of the claims submitted. This comprehensive approach highlights the scheme's commitment to shielding its beneficiaries from fraudulent activities and ensuring rightful utilisation of resources.
The Ayushman Bharat scheme, having recently expanded in October 2024 to include all senior citizens aged 70 and above, now covers six crore senior citizens from 4.5 crore families. This expansion underscores the government's dedication to providing inclusive healthcare benefits. As part of the scheme's governance, a three-tier grievance redressal system is operational at district, state, and national levels, providing beneficiaries with various mediums to file grievances, including a web-based portal and central and state call centres. Jadhav stated that these measures ensure effective and efficient grievance handling, reflecting a structured approach to consumer concerns.
The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) was officially launched on September 23, 2018, and has since grown to become the largest health assurance scheme globally. It offers comprehensive hospitalization benefits for secondary and tertiary care, providing up to Rs 5 lakh per family annually. As a crucial part of the Ayushman Bharat initiative, which was founded on the principles of the National Health Policy 2017, PM-JAY has significantly improved healthcare access for the most marginalized populations in the country.
Through these comprehensive measures, Ayushman Bharat continues to serve as a crucial pillar in India's healthcare landscape, aiming to safeguard financial and medical security for its beneficiaries. With technology-driven monitoring and strict enforcement policies, the scheme strives to minimise fraudulent practices, thereby protecting public resources and ensuring that health benefits reach those genuinely in need. The government's proactive stance in addressing these issues marks a significant step towards more transparent and effective healthcare delivery.