Zero tolerance for fraud in Ayushman scheme: Over 18,000 Grievances Filed, informs MoS Health

New Delhi: The Union Minister of Health and Family Welfare Shri Prataprao Jadhav recently informed the Lok Sabha that a total of 18,184 grievances have been registered on the Central Grievance Redressal and Monitoring System (CGRMS) concerning various issues, including denial of treatment, charges for admission, discharge, or medicines, and the unavailability of Pradhan Mantri Arogya Mitra (PMAM), etc.

In the data presented before the parliament, the Minister informed that AB-PMJAY ensures quality healthcare services to the scheme beneficiaries. The scheme is governed by a zero-tolerance approach to any kind of fraud and abuse and various steps are taken for the prevention, detection and deterrence of different kinds of fraud that could occur in the scheme at different stages of its implementation.

This comes after parliament member Shri Sudama Prasad enquired about the unnecessary surgeries conducted under the AB-PMJAY program following the recent controversy that has raised doubts among citizens about whether to get any free medical treatment from health camps organised by hospitals. 

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The MoS Health was responding to a series of questions asked by parliament member Shri Sudama Prasad who sought to know whether it is true that unnecessary surgeries are done by hospitals empanelled under the PMJAY-Ayushman Bharat Scheme, if so, the action taken/proposed to be taken by the Government against such hospitals, the details of complaints received against private hospitals and diagnostic centres empanelled under the Ayushman Bharat Scheme by patients for providing improper services since the inception of the scheme along with the action taken against these complaints.

Further, the Minister was also asked for the total number of beneficiaries enrolled under Ayushman Bharat Schemes along with the list of beneficiaries having Ayushman Vay Vandana Card, State-wise; and the total amount sanctioned under the said scheme since its inception, State-wise.

In response to the queries, the Minister said, "Regarding the case under reference, an FIR was lodged on 12.11.2024 against the said hospital and the involved doctors. Further, the hospital and the implicated doctors have been suspended from the Ayushman Bharat—Pradhan Mantri Jan Arogya Yojana (AB-PMJAY).

AB-PMJAY ensures quality healthcare services to the scheme beneficiaries. The scheme is governed on a zero-tolerance approach to any kind of fraud and abuse and various steps are taken for prevention, detection and deterrence of different kinds of fraud that could occur in the scheme at different stages of its implementation."

The National Anti-Fraud Unit (NAFU) has been established at the National Health Authority (NHA) and works in close coordination with State Anti-Fraud Units (SAFU) to investigate and take joint action against issues related to fraud and abuse. Appropriate actions including suspension, show cause notice, warning letter de-empanelment of hospitals, de-activation of e-cards, levying penalty on errant hospitals and lodging of FIRs are taken against fraudulent entities, said the Minister.

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. Each level has a dedicated nodal officer and Grievance Redressal Committees to address the grievances. Beneficiaries can file their grievance using different mediums including web-based portal Centralized Grievance Redressal Management System (CGRMS), Central & State call centers, email, letters to State Health Agencies etc. Based on the nature of grievance, necessary action for resolution is taken including coordination with the hospital and providing of support to the beneficiaries in availing treatment under the scheme, added the minister.

As of October 31 2024, a total of 35.8 crore Ayushman cards have been created under the scheme. Similarly, a total of 2.04 million Ayushman Vay Vandana cards have been issued under the scheme till December 2, 2024. 

The Minister said that AB-PMJAY aims to provide health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalization to approximately 55 crore beneficiaries corresponding to 12.37 crore families constituting economically vulnerable bottom 40% of India’s population. 

Under the AB-PMJAY initiative, the central funding is allocated to the States based on the actual usage of the scheme by beneficiaries, within a specified limit. There is no allocation or sanctioned amount designated for individual States.

The details of funds allocated under AB-PMJAY since its inception are as under: