CS favours robust claim scrutiny for swift disbursals
JAMMU, FEBRUARY 28: Chief Secretary, Atal Dulloo Saturday chaired the 11th Governing Council Meeting of the State Health Agency (SHA) to review the progress and performance registered under PMJAY-Sehat under the current Policy Stage which commenced on April 17, 2025.
The meeting, as per an official statement, was attended by Commissioner Secretary, H&ME; Secretary, IT; Secretary, RDD; Secretary, L&E; DG, Codes; CEO, SHA; Principal, GMC Jammu and other concerned officers.
During the meeting, the Chief Secretary emphasized the need for putting in place a robust and foolproof mechanism to weed out fake or fraudulent claims received by the State Health Agency. He stressed that safeguarding the integrity of the scheme is paramount to ensuring that the benefits reach genuine beneficiaries.
The Chief Secretary further underscored the importance of instituting an effective third-party monitoring mechanism to strengthen oversight and accountability. He observed that such independent scrutiny would play a vital role in ensuring that only genuine claims under PMJAY-SEHAT are processed and disbursed by the agency in a timely and transparent manner.
While highlighting the performance of SHA the CEO, Ananth Dwivedi informed that the scheme has registered substantial utilisation across public and private healthcare institutions, reflecting enhanced access to cashless treatment for beneficiaries across Jammu and Kashmir.
As per the details presented during the meeting, it was revealed that from April 17, 2025 to February 25, 2026, a total of 3,52,563 pre-authorizations have been approved under this policy term. Of these, 2,43,967 approvals were accorded to public hospitals and 1,08,596 approvals to private hospitals, demonstrating significant participation from both sectors.
In financial terms, the total amount of pre-authorizations approved during the period stands at ₹666.34 Cr, with ₹444.75 Cr accounted for by public institutions and ₹221.59 Cr by private hospitals.
The Governing Council was further apprised that 3,23,468 claims have been submitted so far, including 2,21,642 claims from public hospitals and 1,01,826 claims from private hospitals. The total value of claims submitted amounts to ₹604.46 crore, with public sector claims accounting for ₹395.36 Cr and private sector claims for ₹209.10 Cr.
In terms of claim settlement, 1,16,667 claims have been paid to date including 85,570 claims in the public sector and 31,097 claims in the private sector thereby translating into a total disbursement of ₹183.09 Cr. Of this, ₹123.86 Cr has been released to public hospitals and ₹59.23 Cr to private healthcare providers.
The meeting was also informed that 28,631 claims have been rejected after due scrutiny, comprising 27,110 claims from public institutions and 1,521 claims from private hospitals. The total amount associated with rejected claims stands at ₹55.58 crore, including ₹52.19 crore in the public sector and ₹3.39 crore in the private sector.
It was highlighted that the total pre-authorization amount of ₹666.34 crore has been achieved over a period of 315 days (April 17, 2025 to February 16, 2026). On a pro-rata basis, the projected pre-authorization outgo for the full 365-day policy period is estimated to reach approximately ₹772 crore, indicating sustained demand and growing trust in the scheme.
The Governing Council underscored the importance of timely claim processing, strengthened monitoring mechanisms, and enhanced coordination between public and private healthcare institutions to ensure seamless delivery of benefits to eligible beneficiaries. The performance under the current policy period reflects the continued commitment of the State Health Agency towards providing financial risk protection and expanding quality healthcare access across Jammu and Kashmir.
