The Indian government has taken strict measures to prevent fraudulent activities under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), a flagship health insurance scheme.
Union Minister of State for Health, Prataprao Jadhav, informed the Rajya Sabha that authorities had rejected 3.56 lakh fraudulent claims worth ₹643 crore and de-empanelled 1,114 hospitals involved in irregularities.
Additionally, 1,504 hospitals were penalised ₹122 crore, and 549 hospitals were suspended due to non-compliance with the scheme’s guidelines.
AB-PMJAY provides an annual health cover of ₹5 lakh per family for secondary and tertiary care hospitalisation, benefiting approximately 55 crore people. The scheme primarily targets the economically weaker sections, covering 12.37 crore families, which make up 40 per cent of India’s population.
The government has recently expanded AB-PMJAY to include all senior citizens aged 70 and above, irrespective of their socio-economic background. Eligible individuals receive the ‘Ayushman Vay Vandana Card,’ which entitles them to free healthcare services up to ₹5 lakh annually.
Senior citizens belonging to families already covered under AB-PMJAY will receive an additional top-up of ₹5 lakh per year. This expansion is expected to benefit around six crore senior citizens from 4.5 crore families.
To tackle fraud and misuse, the government has implemented a strict anti-fraud mechanism. The National Anti-Fraud Unit (NAFU) has been established to detect and prevent irregularities in claim processing.
The authorities have introduced multiple security measures, including Aadhaar-based e-KYC verification for beneficiaries and authentication at the time of service availing.
The Transaction Management System (TMS) has been equipped with automated triggers to detect fraudulent practices, such as inflated billing, ghost claims, duplicate documents, and impersonation.
AI-driven monitoring tools further enhance fraud detection by scrutinising hospital claims in near real time. In addition, hospitals undergo random audits and surprise inspections to ensure compliance with the scheme’s regulations.
A dedicated three-tier grievance redressal system is in place at the district, state, and national levels to address complaints and concerns. Beneficiaries can report grievances through the Centralised Grievance Redressal Management System (CGRMS), call centres, emails, and letters to state health authorities.
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