NEW DELHI: The Centre has detected over 4.6 lakh suspicious claims made under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PM-JAY) from September 2023 to March 2025, latest government data said.
The National Health Authority (NHA) — the world’s largest publicly funded health insurance scheme — also flagged more than 1,33,611 claims amounting to a total of Rs 272 crore as fraudulent.
According to the NHA annual report 2024-25 released at a two-day national review meeting in Bhopal, Madhya Pradesh, the claims were rejected before payment could be made.
Over 4,63,669 suspicious claims have been shared with states for further investigation. The only state which is not implementing the scheme is West Bengal. The NHA’s national anti-fraud unit (NAFU) team has conducted approximately 120 Joint Field Medical audits across various states and UTs.
Also, over 2,283 Desk Medical Audits have been conducted across states, and suspicious entities have been shared with states for further investigation. Stressing that “institutionalising an anti-fraud framework is key to preserving the integrity of the scheme and building trust,” the report said that in the future, predictive analytics, real-time monitoring, and automated checks will be carried out “to proactively detect, deter, and address suspicious activities and fraudulent claims will be further strengthened.”
Launched seven years ago, the scheme provides financial protection against catastrophic health expenditure by offering health coverage of up to `5 lakhs per family annually for secondary and tertiary care hospitalisations.
As of March 31, 2025, the AB PM-JAY has covered 15.14 crore eligible families and an additional 8.57 crore families under state-specific schemes, equivalent to more than 80 crore eligible individuals. It targets the bottom 40% of the population.
By March 31, over 9.19 crore hospital admissions, amounting to approximately `1.29 lakh crores, have been facilitated. While 52% of hospital admissions were in the private sector, 48% were in the public sector. Similarly, 66% of the total amount was allocated to the private sector, compared to 34% for the public sector.
Speaking at the review meeting, Dr Sunil Kumar Barnwal, CEO, NHA, said, “Ayushman Bharat, with its four strong pillars, has benefited over 45 crore people.”
