A month before two beneficiaries of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) died following angioplasty at Khyati Multispeciality Hospital in Ahmedabad, the Gujarat Medical Council (GMC) had, on October 4, suspended a paediatrician from Rajkot from practising medicine for one year.
The move came after allegations that he had falsified medical records to unlawfully admit newborn babies to his hospital and claim benefits from the national health scheme.
Following the action against the accused, Dr Hiren Natwarlal Mashru, his hospital, Nihit Babycare Children Hospital, was also removed from the PM-JAY panel and a penalty of Rs 6.54 crore was imposed.
Officials stated that the fraud claims were submitted throughout nearly 10 months, from July 2023 to May of this year and that the system failed to identify any inconsistencies. Dr Mashru submitted 116 claims totalling Rs 65,47,950 on the PM-JAY website, all of which were later denied.
The GMC decision was the culmination of a lengthy probe into the doctor from Rajkot’s unethical actions and financial and insurance scams. He was charged for improperly claiming compensation from the PM-JAY, the nation’s major health insurance scheme, by admitting healthy children to his NICU.
Nihit Babycare Children Hospital was only approved under PM-JAY for M-3 (neonatal) care. It is located in a building in Rajkot that also houses a diagnostic and physiotherapy facility.
“It was the safeguards in the PM-JAY system itself that caught the fraud. The National Anti-Fraud Unit (NAFU) keeps a close eye on claims made under the scheme. The states are promptly alerted to any unusual trends in claims, treatments or figures. In a similar vein, each individual claim is examined locally. The system also identified this case,” Remya Mohan, Managing Director of the National Health Mission and Deputy CEO of PM-JAY in Gujarat, told a section of the media when asked how it remained hidden for nearly a year.
An official with knowledge of the investigation’s specifics, however, said that “the preliminary investigation into what would turn into this massive fraud came to light in May, when personnel from the Rajkot district health department received phone call recordings between two persons alleged to be Dr Hiren Mashru and one of his employees who had turned whistleblower due to differences with the employer.”
“The mismatched lab reports were ultimately the key component in the investigation, even though the racket itself was exposed when his own employee provided the committee with phone recordings as proof of the accused discussing the manipulation of medical records,” the official stated.
Dr PK Singh, the Chief District Health Officer (CDHO), confirmed that his office’s initial inquiry was based on the phone records.
“We asked Dr Mashru to explain things. When he was unable to do so to our satisfaction, we conducted our own investigation and promptly alerted the State Health Authority (SHA) to the potential misconduct. In the month of May, all of this occurred within a week’s time. By this point, the issue was also being covered by the local media. The inquiry was then taken up by the state team and the insurance company’s auditors,” Singh said.
The inquiry took over a month and a half to conclude and the doctor had to deal with a number of consequences.
As per media reports, Dr Mashru had falsified the blood results of children with absolutely normal health indicators to show that they were experiencing issues and needed urgent medical treatment. Additionally, the reports revealed that the hospital “digitally edited” one patient’s X-rays on a regular basis and utilised several versions of the same to demonstrate reasons for medical treatment for several patients.
“The team compared the lab reports and the reports in the hospital’s medical records that had been uploaded on the PM-JAY portal to seek claims. Both were distinct, demonstrating trickery,” an official said.
Eighteen pathological reports from the Mangalam In-Vitro laboratory that had been falsified by the hospital were discovered during a joint investigation by the State Anti Fraud Unit (SAFU) and a claim audit team from Bajaj Allianz General Insurance Company Limited, the authorised insurance provider in this case.
Additionally, two other labs, Neo Diagnostic Centre and Maruti Diagnosis Centre, informed the investigators that their labs had not given the 98 X-rays that were subjected to the scanner in this case.
The insurance coverage for beneficiaries of the state government’s hybrid Ayushman Bharat Pradhan Mantri Jay Arogya Yojna-Mukhyamantri Amrutam (AB PMJAY-MA) scheme was increased from Rs 5 lakh to Rs 10 lakh on July 11, 2023. The public or private insurer is responsible for up to Rs 1 lakh in claims, with the remaining amount coming from a state government trust.
The State Grievance Redressal Committee (SGRC) made the decision to remove Dr Hiren Mashru and his medical centre from the PM-JAY scheme on October 22.
Furthermore, records from the GMC’s independent investigation showed that Dr Mashru had allegedly illegally admitted newborns to his hospital by falsifying their lab results in order to profit financially from PM-JAY claims. As a result, his licence to practise medicine was suspended for a year, from December 21, 2024 to December 20, 2025.
“We have unanimously passed this order on the basis of all the facts of the matter relating to ethical conduct and precedents of orders in such cases,” stated Dr Nitin Vora, President of the GMC.
In addition, the GMC recommended that PM-JAY officials in the state lodge a police complaint over the situation. But in response to a question concerning criminal prosecution, Dy CEO Remya Mohan stated, “We will adhere to the NHA’s guidelines. The steps outlined in the regulations have already been taken. In certain situations, our department is not responsible for criminal prosecution.”
“We are in receipt of the order passed by the GMC in this case. Later this month, we will bring up the issue in the general body meeting and based on that, we will decide to suspend his membership,” Dr Mehul Shah, President of the Gujarat State Branch of IMA, told a media outlet.
When asked if investigators had questioned the parents of the children who were admitted to Nihit Babycare Children Hospital for the alleged financial gain and if they had suffered any harm as a result of their prolonged and unwarranted hospital stays, Dr Shailesh Anand, General Manager of PM-JAY in Gujarat, responded, “No such incident has been found. We check 4,000 patients daily. All the patients are called on a regular basis.”
Deputy CEO Remya Mohan stated that she would have to investigate the matter even though no case of harm to any child had “come to attention.”
“The ambit of this council is limited to the professional conduct of the medical professional and the documentary proof before it,” Dr Vora stated in reference to the patients’ absence from the GMC probe.
