Uppal said a regular vigilance inquiry had been initiated to “probe the racket thoroughly”. The Punjab Vigilance Bureau has exposed a “big scam worth crores of rupees” under the Pradhan Mantri Jan Arogya Yojana – ‘Ayushman Bharat’ scheme in which “private hospitals obtained health insurance claims from a private insurance company on the basis of fake bills for treatment of beneficiary patients possessing smart health cards”, DGP-cum-Chief Director Vigilance Bureau B K Uppal said here on Wednesday.
“Contrary to this, the insurance firm had rejected hundreds of insurance claims pertaining to government hospitals causing a huge loss to the state exchequer,” Uppal said in a written statement issued to the media.
Uppal said on the basis of inputs received from credible sources, it has come to light that several well-known private hospitals based in Jalandhar, Hoshiarpur and Kapurthala districts have prepared hefty fake bills on the names of smart card holders for their treatment under Ayushman Bharat scheme and took insurance claims from insurance firm.
Uppal said a regular vigilance inquiry had been initiated to “probe the racket thoroughly”.
He said SSP vigilance range Jalandhar Daljinder Singh Dhillon has unearthed this fraud and as per preliminary findings, several fake medical bills of private hospitals had been cleared by the insurance company but on the contrary reimbursement bills forwarded by government hospitals were rejected.
“In this connection, major negligence has been seen at the end of concerned Deputy Medical Commissioners and doctors of state hospitals/primary health centres,” he added.
“The major reason for rejecting the insurance claims of government hospitals by the company was to get extraordinary financial benefits,” Uppal stated, adding that “as a result, the Punjab government has incurred a financial loss during the last one year from these three aforesaid districts”.
He said it was reliably learnt that 1,015 claims of 35 government hospitals were rejected during last one year by the insurance firm. The amount of rejected insurance claims of government hospitals is approximately 52,06,500.
Uppal said, “It is pertinent to mention here that this health insurance scheme is being run in the state of Punjab under Sarbat Health insurance scheme. According to this scheme, 40% premium share as a financial assistance is being paid by Punjab government and the remaining share 60% is contributed by Central government to the insurance firm under this scheme. An amount of Rs 1,000 is being paid annually by the government as premium per family to the insurance firm. In this regard, the Punjab government also issues smart health cards to the poor and underprivileged families. Through this smart card if any beneficiary or his family member gets any serious illness, he/she could be admitted to the listed hospitals under this scheme and avail free cashless treatment up to Rs 5 lakh.
Uppal said, “During investigations it has come to light that a well-known hospital of Sultanpur Lodhi town in Kapurthala district had claimed Rs 4,43,98,450 for the treatment of about 1,282 patients and out of which 519 claims have been rejected. On the basis of these medical bills, the State Health Authority, Punjab, has passed claims of this hospital to the tune of Rs 4,23,48,050. Then insurance company reimbursed the claimed amount to the tune of Rs 1,86,59,150 out of Rs 4,43,98,450 to the said hospital.”
The vigilance chief said that “a patient named Paramjeet Kaur village Turna in Jalandhar district was admitted to the hospital (name withheld not to hamper investigations) for operating gall bladder stone but due to her personal reasons she did not undergo the operation. In this regard, the hospital prepared a fake medical bill of Rs 22,000 for this patient and took reimbursement claim from IFFCO TOKIO under the Ayushman Bharat health insurance scheme.
In another such case, Uppal said, “Patient Sukhjinder Kaur village Sidhupur was admitted to the same hospital for gall bladder operation. She presented her smart health card issued by the Punjab government but the director of this hospital asked the patient that her treatment could not be done with one smart card. In this connection, the hospital director told the patient to either deposit Rs 25,000 in cash or bring six-seven smart cards to avail the benefit of treatment. After this, Sukhjinder Kaur’s family submitted three smart cards belonging to her family members to the hospital under compulsion.”
Uppal said that to cover up the fraud, this hospital made fake videos of Sukhjinder Kaur’s family members by putting them on the hospital beds and taking their signatures on blank papers.
“The administrator of hospital had instructed them to reply on receiving a phone call by saying that they underwent an operation. But all three of them had no ailment. The hospital claimed falsely Rs 25,000 each of three persons for operating only Sukhjinder Kaur. This raised the suspicion that the Ayushman Bharat scheme was being rigged on a large scale by this hospital,” Uppal said.
“In this regard, information gathered by VB Jalandhar Range reveals that several reputed private hospitals based in Jalandhar, Kapurthala and Hoshiarpur have obtained the insurance claims by fabricating huge medical bills in the names of smart health card holders. A total of 35 government and 77 private hospitals have been listed by the Punjab government under this scheme in these three aforesaid districts,” Uppal said.
He stated, “According to reliable input and figures, 4,828 claims of 77 private hospitals were rejected during last one year by the health insurance company. The amount of rejected insurance claims of private hospitals is approximately Rs 5,59,96,407.”