On Friday, the government informed the Lok Sabha that it has taken strict action against fraudulent entities under the Ayushman Bharat Health Insurance scheme, de-empanelling 1,114 hospitals, imposing penalties worth ₹122 crore on 1,504 errant facilities, and suspending 549 hospitals.
Zero-Tolerance Policy on Misuse
In a written reply, Minister of State for Health and Family Welfare Prataprao Jadhav said that AB-PMJAY operates on a zero-tolerance policy. This policy targets misuse and abuse. He added that multiple measures are in place to prevent, detect, and deter irregularities at all stages of implementation.
Robust Anti-Fraud Framework
To enforce this policy, the government has set up the National Anti-Fraud Unit (NAFU). It is responsible for preventing, detecting, and deterring fraudulent activities under AB-PMJAY. “Suitable actions, including de-empanelment, penalties, and suspension of hospitals, have been carried out as reported by the states and Union Territories,” Jadhav stated.
Ensuring Beneficiary Rights
As per empanelment terms, hospitals cannot deny treatment to eligible beneficiaries. If treatment is refused, beneficiaries can lodge complaints. To address such issues, AB-PMJAY has a three-tier grievance redressal system at district, state, and national levels. Dedicated nodal officers and committees operate at each level.
Multiple Avenues for Grievances
Beneficiaries can file grievances via a web-based portal, the Centralised Grievance Redressal Management System (CGRMS), call centres (14555), email, letters to State Health Agencies (SHAs), and other channels. Depending on the grievance, authorities take necessary action, including facilitating treatment for the beneficiary.
Efficient Claims Settlement
Jadhav explained that claims settlement under AB-PMJAY is an ongoing process, managed by respective SHAs. The National Health Authority (NHA) mandates payment within 15 days for intra-state claims and within 30 days for portability claims (when patients seek treatment outside their home state).
Improving Timelines and Capacity
As reported by The Hindu, the scheme has recorded notable year-on-year improvements in average turnaround time for claim settlements. Regular review meetings track progress, while capacity-building activities ensure efficient claims processing.