Punjab, Haryana, and Himachal Pradesh account for over Rs 74 crore in fraudulent claims, prompting stricter enforcement measures.
Massive Insurance Fraud Detected in Ayushman Bharat Scheme
The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), India’s flagship health insurance scheme, has been hit by large-scale fraud, with empanelled hospitals inflating claims. According to data from the National Anti-Fraud Unit (NAFU), fraudulent claims worth Rs 562.4 crore have been detected nationwide, raising serious concerns about misuse and accountability.
Punjab, Haryana, and Himachal Pradesh alone accounted for Rs 74.5 crore, making up 13% of the total fake claims detected.
Breakdown of Fake Claims in Northern States
The Union Health Ministry revealed the extent of fraudulent activities in response to a Rajya Sabha query by MP A D Singh:
- Haryana reported the highest fraudulent claims in the region, amounting to Rs 45.03 crore.
- Punjab followed with Rs 28.7 crore in fake claims.
- Himachal Pradesh reported Rs 75.65 lakh in inadmissible claims.
Irregularities in Beneficiary Registration
Further irregularities were found in beneficiary registration, as multiple people were registered under a single mobile number. Data from the Union Health Ministry in response to MPs Javed Ali Khan and Ramji Lal Suman highlighted:
- Punjab – 30,001 cases
- Haryana – 13,555 cases
- Himachal Pradesh – 2,892 cases
Government’s Zero-Tolerance Policy on Fraud
The National Health Authority (NHA) has reiterated its zero-tolerance policy toward fraud and abuse in AB-PMJAY. To combat fraudulent activities, the National Anti-Fraud Unit (NAFU) works closely with State Anti-Fraud Units (SAFUs) to investigate and take joint action.
The Union Health Ministry has also issued strict guidelines to prevent fraud, including:
- Suspension, blacklisting, or de-empanelment of guilty hospitals.
- Rejection of fraudulent claims and legal action against offenders.
- Implementation of AI-driven fraud detection systems to analyze claims in real-time.
Technology-Driven Fraud Detection Measures
To strengthen enforcement against misuse of AB-PMJAY, the NHA has deployed 57 advanced technologies, including:
- Rule-based triggers and machine-learning algorithms to flag suspicious claims.
- Fuzzy logic and image classification to detect fraudulent patterns.
- De-duplication techniques to prevent duplicate claims.
- Near real-time monitoring dashboards to track irregularities.
- Continuous database monitoring and cleansing to enhance system integrity.
Impact of Stringent Fraud Prevention Measures
Due to these enhanced enforcement efforts:
- 1,114 hospitals have been de-empanelled under AB-PMJAY.
- 549 hospitals have been suspended for suspected fraudulent activities.
- Random audits and surprise inspections have been intensified to verify claim authenticity.
Expanding Ayushman Bharat Coverage
Despite these challenges, the government has expanded AB-PMJAY coverage. Under the new Vay Vandana Card, senior citizens aged 70 years and above are now eligible for Rs 5 lakh per family per year for secondary and tertiary care hospitalization, regardless of their socio-economic status.
Ensuring the Integrity of Ayushman Bharat
With the government tightening fraud detection mechanisms and using advanced data analytics, AB-PMJAY aims to provide genuine beneficiaries with uninterrupted access to healthcare while eliminating fraud.
