Health Insurance Claim Settlement Ratio

Health insurance can help us avoid financial stress, an important lesson the pandemic has taught us and continues to teach us today. Given the rise in hospital bills and medical costs associated with critical illnesses, the importance of a health insurance policy cannot be overstated at this point in time. A comprehensive health insurance plan can significantly reduce the stress of unexpected medical emergencies. Hence, there are a few things that you should consider while buying a health plan to make an informed decision. One of such thing is the claim settlement ratio (CSR) of health insurance companies. Every health insurance company in India has a claim settlement ratio.

Claim Settlement Ratio in Health Insurance

The ratio between the number of claims resolved and the total number of claims in a financial year is known as Claim Settlement Ratio or CSR in health insurance. It helps determine whether the insurer can settle the claims of the customers. For example, if 100 claims were filed during a financial year and 97 of those claims could be settled, then the claim settlement ratio for that particular year for that health insurance company would be 97%.

Claim Settlement Ratio is calculated as (total claims settled / total claims filed) multiplied by 100.

Importance of Claim Settlement Ratio (CSR) in Health Insurance

Mentioned below are some points that show us the importance of the claim settlement ratio in health insurance:

• Provides information regarding the company's ability to pay claims.
• An effective metric for comparing health insurers
• A look at the constancy of insurers in settling claims
• An excellent way to measure a company's reliability

Health Insurance Companies Claim Settlement Ratio

It is essential to compare the health insurance claim ratios of all health insurance companies when purchasing health insurance. A claim settlement ratio (CSR) of more than 85% is considered good. Check out the table below for the claim settlement and solvency ratio of health insurance companies in India: 

*Disclaimer: We RenewBuy do not endorse any specific insurance company or insurance product offered by any insurer. This list is just an illustration of different health insurance companies available in India.

What is Incurred Claim Ratio (ICR) in Health Insurance?

Insured Claims Ratio (ICR) is the ratio of the total claim amount paid by the health insurance company to the total premium amount collected in a financial year. For example, if a health insurance company has a claim ratio of 88%, it means that the insurer pays INR 88 for claim payments for every Rs 100 premium. The remaining INR 12 represents the profit of the insurance company.

Where can I Check Incurred Claim Ratio of an Insurance Company?

Every year IRDAI publishes the incurred claim ratio of all health insurance companies. The insurance regulator provides specific ICRs for various forms of insurance along with the overall incurred claim ratio (ICR) of the health insurance company. Thus, the annual report of IRDAI can be used to estimate the claim ratio incurred by an insurance company for health insurance.

Health Insurance Claim Settlement Process

There are two types of claim settlement processes in health insurance, i.e. cashless claim process and the reimbursement claim process. Below mentioned are both the claims processes in detail:

Cashless Claim Process

Such claims can be filled in case of health insured avail of treatment at the network hospital of the health insurance company.

• Claim Intimation
• Documents Verification
• Documents Approval
• Claim Settlement

Reimbursement Claim Process

If a policyholder decides to get medical treatment at a hospital that is not a part of the insurance company's network hospitals, the policyholder can file a reimbursement claim. In such situations, the policyholder must pay the cost out of his pocket before submitting the claim to the health insurance company for reimbursement.

• Intimate the claim to the health insurance company
• Document Submission
• Document Approval
• Claim Reimbursement

Required Documents For Claim Settlement

Below mentioned are the documents that you need to submit to fill up the claim in health insurance:

• Duly-filled claim form
• ID proof of the claimant
• Medical certificate issued by the doctor
• FIR (In case of an accident)
• Prescription and cash invoice from pharmacy/hospital

*Disclaimer: The documents mentioned above may vary from insurer to insurer.

How to Check Health Insurance Claim Settlement Ratio

You must check and compare the claim settlement ratio of health insurance companies before buying a health plan. This is due to the fact that a medical emergency will already give you a lot of mental stress. The last thing you would want to do in such a situation is to file a claim through a complex claim settlement process and worse, have your claim rejected. An easy and hassle-free claim settlement process will be provided to you by an health insurer with a high claim settlement ratio. So, below mentioned is the process to check the health insurance claim settlement process (CSR):

• The IRDA (Insurance Regulatory and Development Authority) releases their annual report every year, where you can check the list of all the health insurance claim settlement ratio.
• Check the IRDA health insurance claim settlement ratio of your desired insurance provider by visiting the official website of IRDA. View IRDA Annual Report and save the PDF for the most recent financial year.
• Make a list of the health insurance companies with claim settlement ratio in 2022. Higher the claim settlement ratio, better are the chances of getting the claim amount in case of a medical emergency.
• Compare the coverage benefits of the health insurance plans that are now offered by health insurance companies with a high claim settlement ratio.

A health insurance plan can be offered at an affordable premium amount with comprehensive coverage and many additional benefits. However, if that health insurance company has a poor claim settlement ratio, you may find it difficult to settle claims when you need it the most. The whole point of buying health insurance would be failed.

Conclusion

Most health insurance claims are accepted due to the network hospitals of health insurance companies having the cashless facility. Claims will also be accepted if the policyholder is treated in a non-network hospital as long as the treatment is covered within the coverage benefit. Understanding that no insurance company will deny legitimate claim requests is essential.