Legal Challenges in Implementing Ayushman Bharat Scheme
- ByAdmin --
- 02 May 2025 --
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The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is one of India's most ambitious health insurance initiatives, aiming to provide free healthcare coverage of ₹5 lakh per family per year to over 10 crore vulnerable families.
Despite its noble objectives, the scheme faces several legal and regulatory challenges that impact its implementation and effectiveness.
Relevant Legal Framework
- Constitution of India:
- Article 21: Guarantees the right to life, which includes the right to health.
- Article 47: Directs the State to raise the level of nutrition and standard of living and to improve public health (Directive Principles of State Policy).
- Clinical Establishments (Registration and Regulation) Act, 2010:
- Mandates registration and regulation of health institutions offering services under schemes like Ayushman Bharat.
- Mandates registration and regulation of health institutions offering services under schemes like Ayushman Bharat.
- Consumer Protection Act, 2019:
- Provides remedies for patients in cases of deficiency of services by hospitals and insurance providers under the scheme.
Major Legal Challenges in Implementation
1. Regulatory Gaps in Private Healthcare
- Inconsistent Standards:
- Many private hospitals empaneled under AB-PMJAY are not uniformly regulated across different states.
- The absence of mandatory registration under the Clinical Establishments Act in many states leads to varying healthcare quality.
- Accountability Issues:
- Lack of strict compliance monitoring mechanisms makes it difficult to ensure service standards.
2. Fraud and Misuse of Benefits
- Fake Beneficiaries and Claims:
- Multiple reports of fraudulent claims by hospitals using ghost patients or inflating bills.
- Multiple reports of fraudulent claims by hospitals using ghost patients or inflating bills.
- Legal Remedies:
- State governments invoke provisions of the Indian Penal Code, 1860 (Sections 420 – cheating, 468 – forgery for cheating) to prosecute fraudsters.
- State governments invoke provisions of the Indian Penal Code, 1860 (Sections 420 – cheating, 468 – forgery for cheating) to prosecute fraudsters.
- Scheme's Safeguards:
- AB-PMJAY has introduced e-cards and Aadhaar verification, but enforcement remains patchy.
3. Contractual Disputes Between Hospitals and Insurers
- Delayed Payments:
- Private hospitals have filed suits in courts alleging delays and arbitrary rejection of claims by insurance companies.
- Private hospitals have filed suits in courts alleging delays and arbitrary rejection of claims by insurance companies.
- Lack of Uniform Dispute Resolution:
- No standardized mechanism exists across India for resolving disputes swiftly.
- No standardized mechanism exists across India for resolving disputes swiftly.
- Relevant Provisions:
- Contracts between hospitals and insurers are governed by Indian Contract Act, 1872.
4. Data Privacy and Consent Issues
- Massive Collection of Health Data:
- Beneficiaries’ sensitive health information is collected without adequate data protection laws in place.
- Beneficiaries’ sensitive health information is collected without adequate data protection laws in place.
- Concerns Raised:
- Possible violation of the right to privacy as upheld in Justice K.S. Puttaswamy v. Union of India (2017), where privacy was declared a fundamental right under Article 21.
- Possible violation of the right to privacy as upheld in Justice K.S. Puttaswamy v. Union of India (2017), where privacy was declared a fundamental right under Article 21.
- Upcoming Framework:
- The Digital Personal Data Protection Act, 2023 is expected to address some concerns, but gaps still exist.
5. State-Centre Jurisdictional Conflicts
- Healthcare is a State Subject:
- Under Schedule VII, List II (State List) of the Constitution, healthcare primarily falls under state jurisdiction.
- Under Schedule VII, List II (State List) of the Constitution, healthcare primarily falls under state jurisdiction.
- Implementation Issues:
- Some states, citing autonomy concerns, have modified or delayed implementation of Ayushman Bharat (e.g., Delhi, West Bengal).
- Some states, citing autonomy concerns, have modified or delayed implementation of Ayushman Bharat (e.g., Delhi, West Bengal).
- Legal Impact:
- Raises federalism concerns under Article 246, regarding the division of powers.
Recent judicial Interventions
- Delhi High Court Ruling (2022):
- Directed the Central Government to strengthen fraud detection mechanisms and ensure transparency in beneficiary identification.
- Directed the Central Government to strengthen fraud detection mechanisms and ensure transparency in beneficiary identification.
- Supreme Court Observations:
- Emphasized that health policies must comply with the Right to Health under Article 21.
Steps Towards Addressing Legal Challenges
- Stronger Regulatory Framework:
- Make registration under the Clinical Establishments Act mandatory nationwide.
- Make registration under the Clinical Establishments Act mandatory nationwide.
- Fraud Control Measures:
- Setting up dedicated grievance redressal bodies and fast-track courts for Ayushman Bharat-related frauds.
- Setting up dedicated grievance redressal bodies and fast-track courts for Ayushman Bharat-related frauds.
- Data Protection Compliance:
- Implement robust consent frameworks and security standards as per the Digital Personal Data Protection Act, 2023.
- Implement robust consent frameworks and security standards as per the Digital Personal Data Protection Act, 2023.
- Harmonizing Centre-State Relations:
- Greater consultation with states and cooperative federalism approaches.
Conclusion
While Ayushman Bharat is a revolutionary step toward universal health coverage in India, the legal and regulatory hurdles must be systematically addressed to fulfill its promise.
Ensuring robust standards, protecting patient data, preventing fraud, and resolving federal conflicts are key to making healthcare truly accessible and just under Article 21 of the Constitution.
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