All is not well with the government’s flagship health insurance scheme, Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). A CAG report tabled in the Lok Sabha last week, has found glaring loopholes in implementation of the scheme including misappropriation of funds, fake accounts, releasing funds without proper evidence and even claims paid in the name of patients who were already dead. 

Interestingly, the report of the autonomous audit agency found that such cases are relatively high in Kerala, which ranks first in the NITI Aayog Health Index and other social health parameters.

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Launched in September 2018, PM-JAY is touted to be the world’s largest health insurance scheme fully funded by the government. The scheme aims to provide free healthcare to over 50 crore poor families. The scheme provides funding of up to ₹5 lakh per family annually.

As per the scheme, a patient can avail of treatment only once without an Aadhar or an Aadhar enrollment slip. They are further mandated to provide a signed declaration saying that they will produce the Aadhar before their next treatment. However, the CAG report found that 8.2 lakh patients availed of treatment for two or more times without an Aadhar or any other biometric proof for a cumulative claim settlement worth ₹1,678.68 crore.

Kerala cases

Kerala tops the list with the highest number of such cases. The State saw 2.02 lakh patients availing treatments two or more times without biometric verification between September 2018 and March 2021. Cumulatively, they were paid ₹472.64 crore. It was followed by Chhattisgarh which saw ₹234.86 crore in claim payments to such patients.

Dead men pay bills?

The report also highlighted something rather bizarre. Thousands of claims are made against patient names, who were shown ‘dead’ earlier. “The audit noted that patients earlier shown as ‘died’ in the system continued to avail treatment under the Scheme. Data analysis of mortality cases revealed that 88,760 patients died during treatment specified under the Scheme. A total of 2,14,923 claims shown as paid in the system, related to fresh treatment in respect of these patients [sic],” reads the CAG report.

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In 3,903 of such cases, claims amounting to ₹6.97 crore pertaining to 3,446 patients were paid to hospitals. Strangely, in these cases too, Kerala tops the list. In the state, such claims were made in the names of 966 ‘already dead patients. They were paid a claim amount worth ₹2.61 crore. Madhya Pradesh comes next with 403 claims in the name of dead patients.

“The implementation of the Scheme needs improvement in light of the findings made in the report. It is expected that the compliance to the observations and recommendations made in this Report will help in improving the implementation of the Scheme,” the report added.