The fraud claims, said officials, were made in a period of nearly 10 months between July 2023 and May this year, while discrepancies went undetected by the system.
After the action against Dr Hiren Natwarlal Mashru, the accused, his hospital — Nihit Babycare Children Hospital — was also de-empanelled from the PMJAY and a penalty of Rs 6.54 crore was imposed. (Express)
Weeks before two beneficiaries of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) died allegedly after angioplasty at Khyati Multispeciality Hospital in Ahmedabad, the Gujarat Medical Council (GMC) on October 4 had barred a Rajkot-based pediatrician from medical practice for one year after allegations that he falsely admitted newborn babies to his hospital by manipulating their medical records to illegally claim benefits of the national health scheme.
After the action against Dr Hiren Natwarlal Mashru, the accused, his hospital — Nihit Babycare Children Hospital — was also de-empanelled from the PMJAY and a penalty of Rs 6.54 crore was imposed.
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A total of 116 claims uploaded by Dr Mashru, to the tune of Rs 65,47,950 on the PMJAY website, were subsequently rejected.
The GMC action came at the fag end of a longer investigation into financial and insurance frauds linked to the Rajkot-based doctor, and also his unethical behaviour. He was accused of admitting healthy children to his NICU to illegally claim reimbursementfrom the PMJAY, the flagship health insurance scheme of the central government.
Nihit Babycare Children Hospital, which runs out of a building in Rajkot that also has a diagnostic and physiotherapy clinic, was empanelled under PMJAY just for M-3 (neo-natal) treatment.
Asked how it went under the radar for almost a year, Remya Mohan, Managing Director of the National Health Mission and Deputy CEO of PMJAY in Gujarat, told The Indian Express, “It was the safeguards in the PMJAY system itself that caught the fraud. The National Anti Fraud Unit (NAFU) continuously monitors claims under the scheme. Any abnormal patterns in claims or treatments or amounts are immediately red-flagged to the states. Similarly, every individual claim is also scrutinised at the local levels. This case was also flagged by the system.”
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n On October 22, the State Grievance Redressal Committee (SGRC) decided to de-empanel Dr Hiren Mashru and his hospital from the PMJAY scheme. (Express)
However, an official aware of the details of the investigation, told The Indian Express, “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 official said, “While the racket itself came to light when his own employee gave the committee access to telephonic recording as evidence of the accused discussing the manipulation of medical records, it was ultimately the mismatched lab reports that were the lynchpin in the investigation.”
Chief District Health Officer (CDHO) Dr PK Singh confirmed that the preliminary investigation by his office was conducted on the basis of the phone recordings. “We approached Dr Mashru and asked him to explain them. When he couldn’t do so satisfactorily, we did some checking of our own and then immediately informed the State Health Authority (SHA) of the possibility of malpractice. All this happened in about a week in the month of May. By this time, the local media had also begun reporting the matter. The state team and auditors from the insurance company took over the investigation from there.”
It took about one-and-a-half months for the investigation to come to an end, leading to several repercussions for the doctor.
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Documentary evidence collected during the investigations, and seen by The Indian Express, show that Dr Hiren Mashru had allegedly altered the blood reports of children with perfectly normal health parameters to show they were suffering from problems and required immediate medical attention. Further, the reports showed that the hospital repeatedly “digitally edited” X-rays of one patients and used multiple iterations of the same to show cause for medical care in the case of multiple patients.
An official close to the investigation, on condition of anonymity, said, “The team compared the lab reports and the reports in the medical records of the hospital that had been uploaded on the PMJAY portal to seek claims. Both were different, proving manipulation.” A joint investigation by the SAFU (State Anti Fraud Unit) and a claim audit team from Bajaj Allianz General Insurance Company Limited, who is the designated insurance provider in this instance, found 18 pathological reports from Mangalam In-Vitro laboratory that had been manipulated by the hospital. Further, two other labs, Neo Diagnostic Centre and Maruti Diagnosis Centre, told the investigators that 98 X-rays under the scanner in this case, had not been issued from their laboratories.
Under the hybrid Ayushman Bharat Pradhan Mantri Jay Arogya Yojna – Mukhyamantri Amrutam (AB PMJAY-MA) scheme run by the state government in Gujarat,, where insurance cover for beneficiaries was raised from Rs 5 lakh to Rs 10 lakh on July 11, 2023, the (public or private) insurer has a liability to pay claims up to Rs 1 lakh and the remaining is paid from a state government trust.
On October 22, the State Grievance Redressal Committee (SGRC) decided to de-empanel Dr Hiren Mashru and his hospital from the PMJAY scheme.
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Moreover, documents from the independent investigation carried out by the Gujarat Medical Council (GMC) revealed that Dr Mashru had allegedly illicitly admitted even newborns to his hospital by manipulating their laboratory reports to gain monetary benefits through PMJAY claims, based on which his licence to practice was suspended for a year, from December 21, 2024 to December 20, 2025.
Dr Nitin Vora, President of the GMC said, “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.” The GMC also suggested that the PMJAY officials in Gujarat file a police complaint in the matter. However, when asked about criminal prosecution, Dy CEO Remya Mohan said, “We will stick to the guidelines of NHA. We have already taken the actions prescribed by regulations. Criminal prosecution does not fall under the ambit of our department in such cases.”
Dr Mehul Shah, President of the Gujarat State Branch of IMA, told The Indian Express, “We are in receipt of the order passed by the GMC in this case. We will bring up the matter before the general body meeting later this month and a decision to suspend his membership will be taken on the basis of the same.”
Dr Shailesh Anand, General Manager of PMJAY in Gujarat, when asked if investigators had checked with parents of the babies — admitted to Nihit Babycare Children Hospital for the alleged monetary gain — had been caused any harm by their extended, unnecessary stays at the hospital said in a written response, “No such incident has been found… We check 4,000 patients daily… All the patients are called on a regular basis.” He did not elaborate.
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Even Deputy CEO Remya Mohan, only said that while no case of harm to any child had “come to attention”, she would have to look into the matter.
On the absence of patients from the GMC investigation, Dr Vora said, “The ambit of this council is limited to the professional conduct of the medical professional and the documentary proof before it.”
Dr Mashru did not take calls or respond to text messages on related queries.
Brendan Dabhi works with The Indian Express, focusing his comprehensive reporting primarily on Gujarat. He covers the region's most critical social, legal, and administrative sectors, notably specializing at the intersection of health, social justice, and disasters.
Expertise
Health and Public Policy: He has deep expertise in healthcare issues, including rare diseases, Antimicrobial Resistance (AMR), the complex logistics of organ transplants, and public health challenges like drug-resistant TB and heat health surveillance. His on-ground reporting during the COVID-19 pandemic and Mucormycosis was critical in exposing healthcare challenges faced by marginalized communities in Gujarat.
Social Justice and Legal Administration: He reports on the functioning of the legal and police system, including the impact of judicial philosophy, forensics and crucial administrative reforms (. He covers major surveillance and crackdown exercises by the Gujarat police and security on the international border.
Disaster and Crisis Management: His work closely tracks how government and civic bodies respond to large-scale crises, providing essential coverage on the human and administrative fallout of disasters including cyclones, floods, conflict, major fires and reported extensively on the AI 171 crash in Ahmedabad.
Civic Infrastructure and Governance: Provides timely reports on critical civic failures, including large scale infrastructure projects by the railways and civic bodies, as well as the enforcement of municipal regulations and their impact on residents and heritage. ... Read More
