Executive Summary:
The Ministry of Health and Family Welfare addressed concerns regarding fraudulent activities under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (ABPMJAY) in response to questions raised in Lok Sabha. The Ministry detailed the anti-fraud mechanisms in place, actions taken against fraudulent entities, and grievance redressal systems for beneficiaries, while also addressing concerns about claim settlements and denial of treatment. The goal is to ensure proper implementation and prevent misuse of the scheme.
Key Points / Main Content:
* **Anti-Fraud Measures:**
* ABPMJAY operates with a zero-tolerance policy towards misuse and abuse.
* A robust anti-fraud mechanism and a National Anti-Fraud Unit (NAFU) have been established for prevention, detection, and deterrence.
* Actions taken include deempanelment of 1114 hospitals, penalties of Rs. 122 crore on 1504 hospitals, and suspension of 549 hospitals.
* **Beneficiary Rights and Grievance Redressal:**
* Empanelled hospitals cannot deny treatment to eligible beneficiaries.
* A three-tier grievance redressal system exists at District, State, and National levels.
* Beneficiaries can file grievances through web portals (Centralized Grievance Redressal Management System CGRMS), call centers (14555), email, or letters to State Health Agencies (SHAs).
* Necessary action is taken based on the nature of the grievance, including support in availing treatment.
* **Claim Settlement:**
* Claims are settled by respective State Health Agencies (SHAs).
* Guidelines mandate claim payment within 15 days for intrastate hospitals and 30 days for portability claims.
* Regular review meetings and capacity-building activities are conducted for efficient claim settlement.
* Notable improvements have been recorded in the overall average Turnaround Time TAT for claim settlements year on year.
Impact Analysis:
* **Hospitals:**
* *Impact:* Subject to strict monitoring and potential penalties (de-empanelment, fines, suspension) for fraudulent activities or denial of treatment. Must adhere to claim settlement timelines.
* *Action Required:* Ensure compliance with ABPMJAY guidelines, provide treatment to eligible beneficiaries, and settle claims efficiently.
* **Beneficiaries:**
* *Impact:* Protected against fraudulent activities and denial of treatment. Have access to a grievance redressal system.
* *Action Required:* Utilize the grievance redressal mechanisms if facing issues with availing treatment under ABPMJAY.
* **State Health Agencies (SHAs):**
* *Impact:* Responsible for claim settlement and grievance redressal at the state level.
* *Action Required:* Ensure timely claim settlement, address beneficiary grievances, and implement anti-fraud measures effectively.
Key Entities Referenced
Pradhan Mantri Jan Aarogya Yojana Ayushman Bharat Yojana: A national health insurance scheme in India, also referred to as ABPMJAY.
Ministry of Health and Family Welfare: The Indian government ministry responsible for health policy in India.
Lok Sabha: The lower house of the Parliament of India.
National Anti Fraud Unit (NAFU): A unit established under ABPMJAY with the responsibility for prevention, detection and deterrence of misuse and abuse of the scheme.
State Health Agencies (SHAs): Agencies at the state level responsible for implementing ABPMJAY.
Centralized Grievance Redressal Management System (CGRMS): A web-based portal used for filing grievances related to ABPMJAY.
District: A tier of the three-tier grievance redressal system under ABPMJAY.
National: A tier of the three-tier grievance redressal system under ABPMJAY.
GOVERNMENTOFINDIA
MINISTRYOFHEALTH AND FAMILYWELFARE
DEPARTMENTOFHEALTH ANDFAMILYWELFARE
LOK SABHA
UNSTARREDQUESTION NO. 3384
TOBE ANSWERED ON 08THAUGUST,2025
FRAUDULENTACTIVITIESUNDERAB-PMJAY
†3384.SHRIRAKESH RATHOR:
Will the Minister of HEALTHAND FAMILYWELFAREbe pleased tostate:
(a) whether fraudulent transactions under Pradhan Mantri Jan Aarogya Yojana (Ayushman
Bharat Yojana) have increasedinthe recentyears;
(b) if so, the number of cases of fraudulent transactions reported so far and the amount
recoveredfrom them;
(c) whether it is a fact that many listed private hospitals are denying treatment under
Ayushman Bharat Yojanadue todelay indisbursement of outstanding amount;
(d) if so, the detailsthereof;
(e) whether there have been cases of death due to unnecessary surgeries performed by
listed/unpanelledhospitals inthe countryandif so, the detailsthereof; and
(f) the details of the action taken against such fraudulent activities under Ayushman Bharat
Yojana?
ANSWER
THE MINISTER OFSTATEIN THE MINISTRYOFHEALTHAND
FAMILYWELFARE
(SHRIPRATAPRAOJADHAV)
(a) to (f): Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is governed
on a zero-tolerance policy towards misuse and abuse and various steps are taken for
prevention, detection anddeterrence of different kindsof irregularities thatcould occurin the
scheme at differentstages of itsimplementation.A robust anti-fraud mechanism has been put
in place and NationalAnti-FraudUnit(NAFU)hasbeensetupwith the primary responsibility
for prevention,detection anddeterrenceof misuse andabuse underAB-PMJAY.Suitable actions including de-empanelment of 1114 hospitals, levying penalty worth Rs. 122
crore on 1504 errant hospitals and suspension of 549 hospitals have been taken against
fraudulent entitiesasreported bythe States/UTs.
As per the terms and conditions of empanelment, hospitals cannot deny treatment to eligible
beneficiaries of the scheme. In case of denial of treatment by the empaneled hospital,
beneficiariescanlodge grievances.Under AB-PMJAY, a three-tiergrievanceredressal system
at District, State and National level has been created to resolve the issues faced by
beneficiaries in utilizing healthcare services. At each level, there is a dedicated nodal officer
andGrievance Redressal Committees toaddress the grievances.
Beneficiaries can file their grievances using different mediums including web-based portal
Centralized Grievance Redressal Management System (CGRMS), Central & State call
centers (14555), email, letter to State Health Agencies (SHAs) etc. Based on the nature of
grievance, necessary action including providing of support to the beneficiaries in availing
treatmentunderthe scheme, istaken.
Settlement of claims is an ongoing process. Under AB-PMJAY, claims are settled by
respective State HealthAgencies(SHA). NHAhaslaiddown guidelinesfor paymentof claim
tohospitals within 15daysofclaimssubmission for theintra-state hospitals (hospitals located
within State)andwithin 30daysincase of portabilityclaims(hospitals locatedoutside State).
Claims are required to be settled within the timeline specified under the scheme. Notable
improvements have been recorded in the overall average Turnaround Time (TAT) for claim
settlements year on year. Regularreview meetings are organized to take stock of the progress
with regards to the claims. Further, capacity building activities are organised for efficient
claimssettlement.
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