**Executive Summary**
This document is the answer provided by the Minister of State in the Ministry of Health and Family Welfare to an unstarred question raised in Lok Sabha on December 12, 2025, regarding fraud cases of claims under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). It outlines the government's zero-tolerance approach to fraud, the actions taken by the National Health Authority (NHA) in coordination with State Anti-Fraud Units (SAFU), and measures to strengthen anti-fraud mechanisms. The data is current as of November 15, 2025.
**Key Points / Main Content**
* **General Provisions:**
* AB-PMJAY operates on a zero-tolerance approach to fraud.
* The National Anti-Fraud Unit (NAFU) works with State Anti-Fraud Units (SAFU) to investigate and act on fraud cases.
* **Actions Against Fraudulent Entities:**
* Appropriate actions are taken against fraudulent entities, including:
* Suspension.
* Issuance of show cause notices.
* Warning letters.
* De-empanelment of hospitals.
* De-activation of e-cards.
* Levying penalties on errant hospitals.
* Lodging of FIRs.
* **Statistics (As of November 15, 2025):**
* 1184 hospitals have been de-empanelled.
* Penalties amounting to Rs. 231.88 crore have been levied.
* 411 hospitals have been suspended by States/UTs.
* **Anti-Fraud Mechanisms:**
* NAFU uses AI/ML-based automated triggers to flag unusual claims, such as:
* Duplicate entries.
* Inflated procedures.
* Misuse of patient's identity.
* Regular capacity-building workshops and field-level training sessions are conducted.
**Impact Analysis**
**National Health Authority (NHA)**
* **Impact:** NHA is responsible for governing AB-PMJAY with a zero-tolerance approach towards fraud, coordinating with SAFUs.
* **Action Required:** NHA must continue to utilize the NAFU and coordinate with SAFUs to identify and address fraud, implement appropriate actions against fraudulent entities, and employ advanced technologies and training programs to strengthen the anti-fraud framework.
**State Anti-Fraud Units (SAFU)**
* **Impact:** SAFUs work in close coordination with the National Anti-Fraud Unit (NAFU) to investigate and take action on cases of fraud.
* **Action Required:** SAFUs are required to continue to collaborate with NAFU to investigate and act on fraud cases.
**Hospitals**
* **Impact:** Hospitals engaged in fraudulent practices face actions such as de-empanelment, suspension, penalties, and FIRs. Compliant hospitals benefit from a fair and transparent system.
* **Action Required:** Hospitals must ensure compliance with AB-PMJAY guidelines to avoid penalties and potential removal from the program.
**Beneficiaries**
* **Impact:** The measures are intended to protect beneficiaries by preventing misuse of funds and ensuring the integrity of the AB-PMJAY scheme.
* **Action Required:** Beneficiaries should be aware of the anti-fraud measures in place and report any suspected fraudulent activity.
Key Entities Referenced
Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY): A national health insurance scheme aimed at providing financial protection to vulnerable families for secondary and tertiary care hospitalization.
National Health Authority (NHA): The apex body responsible for implementing the AB-PMJAY scheme.
National Anti-Fraud Unit (NAFU): Unit established at the NHA to investigate and act on fraud cases under AB-PMJAY.
State Anti-Fraud Units (SAFU): Units established at the state level to investigate and act on fraud cases under AB-PMJAY, in coordination with NAFU.
MINISTRY OF HEALTH AND FAMILY WELFARE: The central ministry responsible for health-related policies and programs, including AB-PMJAY.
GOVERNMENTOFINDIA
MINISTRYOFHEALTH AND FAMILYWELFARE
DEPARTMENTOFHEALTH ANDFAMILYWELFARE
LOK SABHA
UNSTARREDQUESTION NO. 2217
TOBE ANSWERED ON12TH DECEMBER, 2025
FRAUDCASES OFCLAIMS UNDER AB-PMJAY
2217. SHRIKALI CHARAN SINGH:
Will the Minister of HEALTHAND FAMILYWELFAREbe pleased tostate:
(a) whether the Government has detected cases of fraud, misuse, impersonation or inflated
claims under the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY)
during the last three yearsacross the country;
(b) if so, the details of fraudulent transactions, including the number of hospitals,
beneficiariesandofficials found involved,State/UT-wise andyear-wise;
(c) the total amount of fraudulent or irregular claims identified and the amount recovered so
far;
(d) whether the National Health Authority (NHA) has taken action such as de-empanelment,
suspension, penalty imposition or filing of FIRs against hospitals engaged in fraudulent
practicesincludingrecovery of excess payments, if so, the detailsthereof; and
(e) the steps taken by the Government to strengthen anti-fraud mechanisms such as AI-based
claim scrutiny, real-time risk scoring, audits and biometric verification to prevent misuse of
public funds underAB-PMJAY?
ANSWER
THE MINISTER OFSTATEIN THE MINISTRYOFHEALTHAND
FAMILYWELFARE
(SHRIPRATAPRAOJADHAV)
(a) to (e): Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is governed
on a zero-tolerance approach towards fraud. National Anti-Fraud Unit (NAFU) has been
established at National Health Authority which works in close coordination with the State
Anti-Fraud Units (SAFU) toinvestigate and take action on cases of fraud.Appropriate action
including suspension, issue of show cause notices, warning letter, de-empanelment of
hospitals, de-activation of e-cards, levyingof penaltyon errant hospitals and lodgingof FIRs,
are takenagainst fraudulent entities.As on 15.11.2025, 1184 hospitals have been de-empanelled, penalties amounting to Rs.
231.88 crore have been levied against fraudulent entities and 411 hospitals have been
suspended bythe States/UTs.
NAFU uses AI/ML-based automated triggers toflag unusual claims such as duplicateentries,
inflated procedures or misuse of patient’s identity. Regular capacity-building workshops and
field-level training sessions are conducted to strengthen the overall anti-fraud framework of
AB-PMJAY.
*****