Parliament Question: Beneficiaries and claims settled under AB-PMJAY

GOVERNMENTOFINDIA MINISTRYOFHEALTH AND FAMILYWELFARE DEPARTMENTOFHEALTH ANDFAMILYWELFARE RAJYASABHA UNSTARREDQUESTION NO. 2841 TOBE ANSWERED ON17TH MARCH, 2026 BENEFICIARIESANDCLAIMSSETTLEDUNDERAB-PMJAY 2841. SHRIG.C. CHANDRASHEKHAR: Will the Minister of HEALTHAND FAMILYWELFAREbe pleased tostate: (a) the beneficiaries covered and claims settled under Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)during the last two years; (b) the numberandvalue of fraud/irregularity cases detectedandrecovered; and (c)the steps takentoimprove pre-authorisation andpost-audit controls? ANSWER THE MINISTER OFSTATEIN THE MINISTRYOFHEALTHAND FAMILYWELFARE (SHRIPRATAPRAOJADHAV) (a) to (c): Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) provides health coverage of Rs. 5 lakh per family per year for secondary and tertiary care hospitalization to 12 crore families constituting bottom 40% of India's population. In March 2024, approximately 37 lakh families of Accredited Social Health Activists, Anganwadi Workers and Anganwadi Helpers were included under the scheme. The scheme was further expanded to cover 6 crore senior citizens of age 70 years and above belonging to 4.5 crore familiesirrespective of theirsocio-economic status. AB-PMJAY is governed on a zero-tolerance approach towards fraud. National Anti-Fraud Unit (NAFU) uses AI/ML-based automated triggers to flag unusual claim patterns such as duplicateentries, inflated proceduresor misuse of patientidentityetc. NAFU works in close coordination with the State Anti-Fraud Units to investigate and take action against cases of fraud. Appropriate actions including suspension, warning letter, de- empanelment of hospitals, levying penalty lodging of FIRs are taken against fraudulent entities. Pre-authorization is the first step to provide cashless treatment to eligible beneficiaries. The following steps have beentakento improve the pre-authorization: National Health Authority (NHA) has enabled retrospective pre-authorization - allowing public hospitals to raise pre-auth requests up to five days and private hospitals up to three days from the date of admission - thereby ensuring life-saving treatmentisnot denied due toproceduralconstraints.  Further, NHA has enabled auto-approval of pre-authorization for 90 high utilisation packages and low-risk medical procedures. These procedures are approved automatically on pre-authorization submission. For other procedures, a maximum Turn-Around Time norm of six hours isfollowed.  NHA has created separate, dedicated sections within each hospital's login to view incoming pre-authorization queries, respond to them, and process them - all in one place. This makes it easier to track pending cases, take action on time, and manage the overallpre-authorization process more effectively. *****