CAG: ‘Dead’ patients got reimbursement under PMJAY

Bhartesh Singh Thakur

Chandigarh, August 9

There were 406 claims of 354 patients, cleared under the Ayushman Bharat-Pradhan Mantri Jan Arogya Scheme (AB-PMJAY) in Haryana, pertaining to those who were earlier shown as ‘died’ during her/his earlier treatment availed under the scheme. In these cases, Rs 54 lakh was paid, reveals a Comptroller and Auditor General (CAG) report, tabled before Parliament yesterday.

Not just that, there were 2,667 cases involving 1,421 patients, including 620 females and 801 males, who were found to have taken treatment in multiple hospitals during the same hospitalisation period. A total of 134 hospitals were involved in these cases, as per the report.

CAG said the reasoning that these cases could be pertaining to scenarios, where a baby was born in one hospital and shifted to neo-natal care in another hospital, could not be accepted, as male patients were also involved.

The AB-PMJAY provides a cover of Rs 5 lakh per family per year for secondary and tertiary care hospitalisation across public and private-empanelled hospitals in India. Out-patient care is, however, not covered under PMJAY.

A total of 4.99 lakh claims were settled in Haryana worth Rs 589.24 crore while 54,979 cases were under process for settlement worth Rs 79.54 crore, as of November 2022. The scheme was launched in 2018.

CAG also found that five hospitals in the state reflected higher occupancy than bed strength to claim reimbursement.

Scheme guidelines stipulate that if a family member does not have an Aadhaar card, she/he is still eligible but can get treatment only once without an Aadhaar or an Aadhaar enrolment slip. A signed declaration is taken from the beneficiary that they do not possess an Aadhaar card and understand that they will need to produce an Aadhaar or the enrolment slip prior to the next treatment.

There are 1.42 lakh claims in Haryana, who availed their second and onward treatment without Aadhaar authentication worth Rs 74.32 crore, the report said.

Also, Rs 8.49 lakh was paid against 114 disabled cards in the state. In Haryana, a comparison of Haryana pensioner’s database with the scheme database revealed that 114 pensioners were included as beneficiaries, who were ineligible, and had availed treatment costing Rs 26.81 lakh.

The National Health Authority several trigger alerts for the identification of suspicious beneficiary registration under the scheme. These cases are forwarded to the State Health Authority’s anti-fraud teams for investigation.

In the case of Haryana, there were 19,338 (22.1%) triggers that were proved fraud pertaining to 6,445 cards while 34,647 triggers pertaining to 11,537 cards remained pending. A total of 87,660 triggers were generated in the case of the state, of which 33,675 were found genuine.

CAG found that a recovery of Rs 36.67 lakh was imposed on defaulting hospitals, but Rs 16.85 lakh was yet to be recovered.