Union Health Ministry Cracks Down On Fraud In AB-PMJAY; 3,167 Hospitals Found Guilty

In a major crackdown on fraudulent practices under the central health flagship Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), at least 3,167 hospitals have been found guilty of violations since the inception of the central flagship. This was informed by the Union Health Ministry in Rajya Sabha recently.

Of these, 1,114 hospitals were de-empanelled, penalties amounting to Rs 122 crore were imposed on 1,504 facilities, and 549 hospitals were suspended, said Union Minister of State for Health Prataprao Jadhav in a written reply on August 19.

He said that a robust anti-fraud mechanism has been institutionalised, led by the National Anti-Fraud Unit (NAFU) under the National Health Authority (NHA). It works in coordination with State Anti-Fraud Units (SAFUs) to detect, investigate, and act against irregularities. Real-time dashboard access has been provided to all States and Union Territories to enhance monitoring and accountability.

Jadhav shared these details in response to a query by Member of Parliament Vivek K Tankha.

The Minister said that AB-PMJAY is governed on a zero-tolerance policy towards fraud and abuse and various steps are taken for prevention, detection and deterrence of different kinds of irregularities that could occur in the scheme at different stages of its implementation.

NHA provides all States and Union Territories with access to robust real time dashboard monitoring thereby enhancing transparency and accountability.

The AB-PMJAY is a flagship scheme of the Government that provides health coverage of Rs 5 lakh per eligible family per year for secondary and tertiary care hospitalizations. The Government has now expanded it to provide free treatment benefits up to Rs5 lakh per year to all senior citizens aged 70 years and above, irrespective of their socio-economic status.

Expansion in treatment is done by inclusion of new procedures, empanelment of new hospitals, inclusion of new beneficiaries and other improvements as per requirements from time to time, said an official from the Union Health Ministry.

Settlement of claims is an ongoing process. Under AB-PMJAY, claims are settled by respective State Health Agencies (SHA). NHA has laid down guidelines for payment of claim to hospitals within 15 days of claims submission for the intra-state hospitals (hospitals located within State) and within 30 days in case of portability claims (hospitals located outside 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.

Last month the Government in reply to a query by MP Raani Ajani Ashokrao Patil had said that as per the terms and conditions of empanelment, hospitals cannot deny treatment to eligible beneficiaries of the scheme. In instances other than treatment denial due to exclusion by the empaneled hospital, beneficiaries can lodge grievances.

He elaborated that under AB-PMJAY, a three-tier grievance redressal 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 and Grievance Redressal Committees to address 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 treatment under the scheme, is taken.

As of August 2025, over 41 crore Ayushman cards have been issued across States and Union Territories. These cards enable eligible families to access cashless hospitalization services up to Rs5 lakh annually. Importantly, the government has expanded eligibility criteria, most recently including 6 crore senior citizens aged 70+ under the Vay Vandana initiative, regardless of socio-economic status. This broadening reflects the government's intent to make universal health coverage a reality.

More than 9.84 crore hospital admissions, amounting to Rs 1.40 lakh crore, have been authorised under AB-PMJAY since its inception. A look at the state-wise figures reveals significant disparities in utilization.

Among the top performers in hospital admissions are Karnataka which leads with 1.24 crore admissions (Rs9,675 crore), Andhra Pradesh with 86.4 lakh admissions (Rs19,261 crore – the highest in monetary terms), Chhattisgarh (76.8 lakh admissions, Rs 9,265 crore), Gujarat (69.8 lakh admissions, Rs 16,165 crore), Uttar Pradesh (68.2 lakh admissions, Rs 10,986 crore). At the same time, Madhya Pradesh issued 4.35 crore cards, but admissions were just 60.2 lakh (Rs 9,610 crore), Bihar issued 3.91 crore cards, with only 21.3 lakh admissions (Rs 2,824 crore).

This disparity indicates underutilization of the scheme in certain populous states, possibly due to awareness gaps, healthcare infrastructure challenges, or administrative hurdles, admitted the official.