Mumbai: As many as 15,407 suspicious health insurance claims have been detected during a preliminary scrutiny of Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana and the Mahatma Jyotirao Phule Jan Arogya Yojana in Maharashtra, prompting the state government to form an SIT.
According to a Government Resolution (GR) issued on Wednesday, the suspected irregularities pertain to claims made between 2024 and 2026.
The GR stated that the state government had earlier directed district civil surgeons and district health officers to conduct physical verification of beneficiaries in all the 15,407 cases.
However, following a review meeting chaired by Chief Minister Devendra Fadnavis on July 10, the government decided to constitute a Special Investigation Team as the alleged fraud appeared to span multiple districts.
Nashik Divisional Commissioner Pravin Gedam will head the SIT. The deputy secretary handling MJPJAY in the Public Health Department will serve as a member secretary. The Medical Education Department will also provide expert doctors to assist the SIT whenever required.
The SIT’s mandate includes investigation of hospital-level irregularities, fake or medically unnecessary claims.
It will also probe inflated treatment procedures, irregularities in hospital empanelment and renewal, use of unauthorised persons or middlemen during patient registration, large-scale registrations linked to the same mobile number or identity proof, and the possible involvement of district coordinators, third-party agencies and other stakeholders associated with the schemes, the government said.
The panel has been tasked with identifying deficiencies in the empanelment, claim approval and monitoring processes under the two health insurance schemes and recommending corrective measures to plug systemic loopholes.
The SIT has been directed to submit its report to the state government within 30 days of its formation. The State Health Assurance Society will provide the required manpower and technical assistance. The daily expenditure on the SIT’s functioning will be met from the society’s administrative budget, the GR added.
The AB-PMJAY scheme of the Central government aims to provide free access to health insurance coverage for low-income earners, extending Rs 5 lakh cover per family per year for medical treatment in empanelled hospitals.
The MPJAY is a flagship cashless health insurance scheme run by the Maharashtra government, integrated with AB-PMJAY. It provides state residents comprehensive coverage up to Rs 5 lakh per family annually for designated secondary and tertiary medical treatments across empanelled hospitals.
