National Anti-Fraud Unit finds ineligible people claiming medical cover by faking relationship with parent-beneficiary
Fraudsters are coming up with ingenious ideas to take the Central government for a ride when it comes to the ‘Pradhan Mantri Jan Arogya Yojana’ (PM-JAY) or the Ayushman Bharat initiative, says the National Anti-Fraud Unit (NAFU), which monitors outliers in the scheme.
In one such bizarre case, NAFU officials noticed that claims had been raised under the PM-JAY for as many as eight deliveries by women in one house at the same time. “This is impossible. How can eight women be pregnant at the same time, that too in the same home?,” a senior NAFU official exclaimed.
Investigations revealed that up to eight ineligible pregnant women, unrelated to each other, had gotten themselves enrolled in PM-JAY through fake e-cards. These cards were made by faking relationship with a PM-JAY parent-beneficiary. PM-JAY uses Socio-Economic Caste Census Data (SECC) to ascertain beneficiary families and primarily records the name of the head of the family. Other family members get e-cards based on proving their relationship with the head of the family.
“In some cases, we found that village entrepreneurs in common service centres (CSCs), who get e-cards made, had stolen parent beneficiary identities from SECC data, and through impersonation, established a familial link between otherwise ineligible strangers and the parent beneficiary; they later made fake e-cards for them,” the official explained.
The fraudsters establish fake family links by showing a forged marriage certificate, and get registered as a daughter-in-law of a beneficiary family. “In that case, you can retain your original name and identity cards, but just have to produce a fake marriage certificate to procure an e-card,” said the official. Other admissible documents to add names of family members at a later stage include a ration card, a birth certificate or an adoption certificate linking the member to the SECC parent beneficiary. “Any of these documents can be forged,” said the official.
In another case, in Jammu and Kashmir, multiple patients linked to one beneficiary in the same house had undergone a surgery for bladder stones.
Hospitals in cahoots
Each family (typically with four or five members) is assured a medical cover of ₹5 lakh annually. “The entire amount is never utilised within a year by the family. This hefty amount in an SECC registered beneficiary’s family wallet leaves a massive space for fraud. First Information Reports have been lodged with the police against CSCs in Uttar Pradesh and Haryana in this regard. We have also moved to recover money in cases where hospitals and ‘Arogya Mitras’ were in cahoots. In certain cases, wallets of SECC beneficiaries have been mysteriously exhausted, but a plan for reimbursement has not been chalked out yet,” said the official.
Such occurrences have led the National Health Authority (NHA) to step up its due diligence. “Whenever a patient gets admitted through linkage to the parent-beneficiary, we call the parent-beneficiary from our database to ask if the patient is related to him/her. Every time a patient is admitted, and through each step of insurance procedure, a text message is sent to the parent beneficiary,” said the official.
However, there is no mechanism in place currently to detect all frauds. “Our staff manually monitor the outliers that reflect on the system. So, we are not able to capture all frauds that may be occurring. We are working on developing systems through artificial intelligence and algorithms, which will automatically red-flag the outliers,” said the official.
Also, NHA has shut down 154 fake websites and up to 590 fake mobile phone applications that claim to enrol persons in PM-JAY by charging money.