Lok Sabha Question No. 3384 (UNSTARRED), answered on 2025-08-08
Subject: Fraudulent Activities under AB-PMJAY
Ministry: HEALTH AND FAMILY WELFARE
Asked by: Shri Rakesh Rathor

## GOVERNMENTOFINDIA MINISTRYOF HEALTH AND FAMILYWELFARE DEPARTMENTOFHEALTH ANDFAMILYWELFARE

## LOK SABHA UNSTARRED QUESTION NO. 3384 TO BE ANSWERED ON 08 TH AUGUST, 2025

## FRAUDULENTACTIVITIESUNDERAB-PMJAY

## †3384. SHRI RAKESH RATHOR:

Will the Minister of HEALTHAND FAMILYWELFARE be pleased to state:

- (a) whether fraudulent transactions under Pradhan Mantri Jan Aarogya Yojana (Ayushman Bharat Yojana) have increased in the recent years;
- (b) if so, the number of cases of fraudulent transactions reported so far and the amount recovered from them;
- (c) whether it is a fact that many listed private hospitals are denying treatment under Ayushman Bharat Yojana due to delay in disbursement of outstanding amount;
- (d) if so, the details thereof;
- (e) whether there have been cases of death due to unnecessary surgeries performed by listed/unpanelled hospitals in the country and if so, the details thereof; and
- (f) the details of the action taken against such fraudulent activities under Ayushman Bharat Yojana?

## ANSWER THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI PRATAPRAO JADHAV)

- (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 and deterrence of different kinds of irregularities that could occur in the scheme at different stages of its implementation. A robust anti-fraud mechanism has been put in place and National Anti-Fraud Unit (NAFU) has been set up with the primary responsibility for prevention, detection and deterrence of misuse and abuse under AB-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 entities as reported by the 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, beneficiaries can lodge grievances. 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.

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. Regular review meetings are organized to take stock of the progress with regards to the claims. Further, capacity building activities are organised for efficient claims settlement.

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