One of my clients recently had a case which I am explaining below and if you are stuck in such similar situation, here is what to do.

Note: Due to attorney-client privilege, I cannot disclose complete case details or identify the actual parties involved. However, I am sharing the essential facts and legal approach so that if you find yourself in a similar situation, you can understand the available solutions and legal remedies.

Mr.X’s mother was admitted to ABC Private Hospital in City A for medical treatment. The hospital was empanelled under the government health scheme and actively used the family’s health card for treatment authorization. However, the hospital’s billing practices raised serious concerns. While approximately Rs. 85,000 was already charged to the government scheme, the hospital simultaneously demanded Rs. 45,000 in cash payments without providing proper receipts. Additionally, they processed Rs. 15,000 through online payment. This dual billing system – claiming government reimbursement while collecting unauthorized cash payments – constituted healthcare fraud. The family realized they were victims of systematic billing irregularities when other patients reported similar experiences at XYZ Hospital.

Advice in Such Cases

Consult with Lawyer: The very basic and important step to start is talk to Lawyer / advocate. You should not hesitate in paying his consultation fee i.e. might be in range of Rs. 10,000 to 50,000 depends case to case. He is helping you in this situation to come out. He is expert in the domain and can help you explain the procedure which you might have never explored. A good lawyer can get the issues resolved much faster than you think.

• Document all payment transactions immediately, including cash payments without receipts
• Contact the health scheme authority to report unauthorized billing practices
• File complaints with healthcare regulatory authorities for billing irregularities
• Preserve all medical records and correspondence with hospital administration

Applicable Sections of Law

Under the Bharatiya Nyaya Sanhita (BNS), several provisions apply to healthcare fraud cases. Section 318 covers cheating and dishonestly inducing delivery of property. Section 316 addresses criminal breach of trust by public servants or persons in fiduciary capacity. Section 61 covers criminal conspiracy when multiple hospital staff are involved. Under Bharatiya Nagarik Suraksha Sanhita (BNSS), Section 173 governs investigation procedures for economic offenses. Healthcare fraud also falls under various healthcare regulations and scheme-specific provisions that mandate proper billing practices and prohibit dual charging systems.

If You Are the Complainant

• File FIR at the nearest police station citing fraud and criminal breach of trust
• Submit detailed complaint to healthcare scheme authority with billing evidence
• Approach state healthcare regulatory commission for investigation into billing practices
• Maintain comprehensive records of all financial transactions and medical documentation
• Coordinate with other affected patients to establish pattern of fraudulent billing

If You Are the Victim

• Immediately stop making any additional cash payments to the hospital administration
• Request detailed breakdown of all charges and government scheme utilization
• Contact scheme helpline to verify authorized expenses and report unauthorized charges
• Seek alternative healthcare facility if current treatment permits safe transfer
• Document all interactions with hospital staff regarding billing and payment demands

How the Police Behave in Such Cases

Police typically treat healthcare fraud as economic offense requiring detailed investigation. They examine billing records, interview hospital staff, and coordinate with healthcare scheme authorities. Investigation focuses on establishing fraudulent intent and systematic billing irregularities. Police may request financial records from both hospital and scheme administrators. Economic offense cell handles such cases with specialized procedures for document verification and financial audit.

FAQs People Normally Have

Can hospital charge additional fees under government scheme? No, empanelled hospitals cannot demand extra payments for covered treatments.

What if hospital claims scheme coverage is insufficient? Hospitals must provide detailed justification and seek pre-approval for additional charges.

Is cash payment without receipt illegal? Yes, hospitals must provide proper receipts for all payments and cannot demand undocumented cash.

Can we recover illegally collected money? Yes, through legal proceedings and regulatory complaints, illegal payments can be recovered.

What Evidence Is Required?

• Government health scheme card and authorization documents
• All payment receipts, bank statements, and transaction records
• Medical bills, treatment records, and discharge summaries
• Communication records with hospital staff regarding payments
• Scheme utilization statements from government authorities
• Witness statements from other affected patients
• Hospital empanelment documents and billing authorization records

How Long Will the Investigation Take?

Healthcare fraud investigations typically require 6-12 months for completion. Initial inquiry by healthcare authorities takes 2-3 months. Police investigation involving financial audit may extend 8-10 months. Regulatory proceedings run parallel and conclude within 6 months. Complex cases with multiple victims or systemic fraud may require additional time for comprehensive investigation.

Advocate Sudhir Rao, Supreme Court of India