High-value claims made by Ayushman Bharat beneficiaries are increasing, reports say. The scheme – officially the Pradhan Mantri Jan Arogya Yojana (PMJAY) – offers insurance coverage to economically vulnerable families of up to Rs 5 lakh per family per year. Estimates project that, by the end of the year, high-value claims (those over Rs 30,000) will account for 32 percent of payouts under the scheme. These payouts are expected to be worth around Rs 2,300 crore. High-value claims account for seven percent of total claims under the scheme.
Data provided by the National Health Authority (NHA) says that approximately 36,000 households have made claims of Rs 1 lakh and 354 have made claims using the Rs 5 lakh limit. Thus far, 37.7 lakh hospital visits have been covered under Ayushman Bharat according to the NHA. Union Health Minister Dr Harsh Vardhan informed MPs last month that 10.74 crore families were covered under Ayushman Bharat.
The scheme has not all been smooth sailing, however. Earlier this month, it was reported that Prime Minister Narendra Modi was displeased with the performance of some states including Arunachal Pradesh, Bihar, Goa, Nagaland, and Sikkim regarding Ayushman Bharat. The minutes of a meeting he chaired at the end of July said they “need to pay more attention [to] the scheme…states/[union territories] should increase awareness amongst beneficiaries about the Ayushman Bharat scheme.” In the case of Bihar, it was found earlier this year that the state government had spent less than one-third of funds it was allocated for implementation of the scheme.
Fraud was also flagged. Some of the hospitals empanelled by the scheme have been accused of financial impropriety to reroute funds from the scheme, with common means of doing so including ‘ghost charges’, using fake beneficiary cards, and even charging for procedures of a ridiculous nature such as performing hysterectomies on men. As a result, multiple facilities have been de-empanelled from administering services under the scheme.