Rs 10 Crore Ayushman Bharat Fraud in UP: Over 6000 fake claims approved

Lucknow: A major scam involving fraudulent medical insurance claims worth Rs 10 crore under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) and Mukhyamantri Jan Arogya schemes has been uncovered at multiple private hospitals across Uttar Pradesh. An FIR was registered at Hazratganj police station on Monday after irregularities were flagged during a routine audit.

The complaint, filed by BK Srivastava, State Nodal Officer of the State Agency for Comprehensive Health and Integrated Services (SACHIS), alleges large-scale irregularities in the submission and approval of claims by private hospitals empanelled under the two health schemes.

According to the FIR, between May 1 and May 22, 2025, a total of 6,239 high-value insurance claims from 39 private hospitals were fraudulently approved and paid through the National Health Authority's online portal. These approvals occurred largely during odd hours—late at night or outside working hours—raising suspicions about the legitimacy of the claims.

Investigators found that login credentials of key officials — including those belonging to the Implementation Support Agency (ISA), financial officers, and the CEO of SACHIS — had been misused to process and approve claims without authorisation.

The fraudulent activity involved unauthorised access and digital manipulation of login IDs such as UP003507, UP008126, UP008171, UP008038, UP008039 (ISA users), UP001730, UP003881 (Finance/Accounts), and UP008296 (CEO-SACHIS), reports TOI.

These IDs were used to approve claims without the knowledge or consent of the actual users. ISA officials have denied any role in the fraudulent activity, stating that none of the disputed claims were routed through their system as per protocol.

Under standard operating procedures, hospital claims are submitted after treatment and must go through multiple levels of scrutiny, including medical auditing by ISA, financial verification by SACHIS, and final approval by the CEO. However, this process was entirely bypassed, with fraudulent claims being approved using compromised login credentials.

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The scam was uncovered when internal office audits noticed a pattern of large, disproportionate payouts originating from a finance manager's login that was not in use by the designated officer during the time of those transactions. Subsequent verification confirmed that online recommendations for claim settlements were made without any actual input from the registered users.

The audit also revealed that many of the hospitals receiving the payments either did not qualify under the scheme or had inflated their treatment data significantly.

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Further investigation and forensic audits are now underway. Authorities believe the actual scale of the scam could be even larger than Rs 10 crore once all suspicious transactions are reviewed.