The Indian government has taken stringent actions against fraudulent practices in the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), including de-empanelling 1,114 hospitals, imposing penalties totaling Rs 122 crore on 1,504 errant facilities, and suspending 549 others, as reported by states and Union Territories.

Minister of State for Health and Family Welfare Prataprao Jadhav informed the Lok Sabha that the scheme operates on a zero-tolerance policy for misuse, with robust mechanisms like the National Anti-Fraud Unit (NAFU) dedicated to preventing, detecting, and deterring irregularities at every implementation stage.

These measures address various abuses, such as fake claims, unauthorized treatments, and denial of services to eligible beneficiaries, who number over 35 crore across India as of mid-2025. For context, AB-PMJAY, launched in 2018, provides up to Rs 5 lakh per family annually for secondary and tertiary care hospitalization, with more than 28,000 hospitals empanelled nationwide. Fraud detection has intensified through AI-driven audits and beneficiary verification, leading to a 25 percent rise in identified cases compared to 2024, according to health ministry data.

Jadhav emphasized that hospitals must not deny treatment to valid beneficiaries, with a three-tier grievance redressal system in place at district, state, and national levels. Beneficiaries can report issues via a web portal, the Centralized Grievance Redressal Management System (CGRMS), a toll-free helpline (14555), email, or letters to State Health Agencies (SHAs). This has resolved over 50,000 complaints in the past year, ensuring timely support and treatment access, particularly in rural areas where the scheme has issued more than 6 crore e-cards since inception.

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Claim settlements remain a priority, with guidelines mandating payments within 15 days for intra-state hospitals and 30 days for inter-state portability claims. The National Health Authority (NHA) reports improved turnaround times, driven by regular review meetings and capacity-building for efficient processing. This has facilitated over Rs 1 lakh crore in claims paid out by 2025, benefiting vulnerable populations and reducing out-of-pocket healthcare expenses by an estimated 40 percent in participating states.

The crackdown aligns with broader efforts to strengthen public health insurance, including integration with state schemes and expansion to cover more ailments. Observers note that sustained vigilance could further enhance trust in AB-PMJAY, which has already averted millions of impoverishments due to medical costs, while deterring future fraud through stricter empanelment criteria and real-time monitoring.

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