Fake Health Insurance Claims in Ayushman Bharat

Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, the world’s largest health insurance scheme fully financed by the government, has been plagued by fake health insurance claims. Hospitals in Haryana, Punjab, and Madhya Pradesh have been found inflating insurance claims.

Out of the 6.66 crore claims processed by the National Anti-fraud Unit, 2.7 lakh claims were found to be fake, which accounted to Rs 562.4 crore. Among them, majority of the fake claims were from the three states which amounted to 74.5 crore. The claims were found to inadmissible, by the National Anti-fraud Unit, due to reasons such as abuse, misuse, or incorrect entries.

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was launched on 23rd September 2018 in Ranchi, Jharkhand by the honorable Prime Minister of India, Narendra Modi. AB-PMJAY is fully funded by the Government and the cost of implementation is shared between the Central and State Governments.^[1] It is the second component of Ayushman Bharat, a flagship scheme of the Government of India launched to achieve the vision of Universal Health Coverage (UHC). 

In an attempt to strengthen enforcement against misuse and abuse under AB-PMJAY, the National Health Authority has issued guidelines defining several punitive measures like suspending, blacklisting, or de-impaneling medical institutions that are found guilty of malpractice.

Among the three states, Haryana reported the highest number of fake claims which amounted to Rs 45.03 crore, followed by Punjab and Himachal Pradesh with Rs 28.7 crore and Rs 75.65 lakh respectively. The data regarding the 'health insurance scams' was shared by Union health ministry in Rajya Sabha in response to a query made by MP A D Singh questioning the fake billing under AB-PMJAY.

Experts say that for ensuring successful working of AB-PMJAY, a zero-tolerance policy needs to be implemented when it comes to fraud and abuse. They also think that real-time monitoring and AI-based systems should be made compulsory in hospitals to enhance fraud detection. Additionally, they also suggest audits and inspections by the government agencies to avoid such fraudulent claims.

References:

1. “About PM-JAY - National Health Authority | GOI,” n.d., http://nha.gov.in/PM-JAY. (Accessed on February 15, 2025)

(Input from various sources)

(Rehash/Jithin Paul/MSM)