Health Insurance Claim Settlement Ratio

Health insurance claim settlement is like a process where you, as a policyholder, ask your insurance company to cover the medical services mentioned in your health insurance plan. So, you can either get treatment without paying cash upfront (cashless) or pay for the services and later ask the insurance provider to refund you.

The best Claim Settlement Ratio of health insurance is like looking at how well an insurance company keeps its promise to pay out when policyholders make legitimate claims. The highest claim settlement ratio in health insurance is often considered a positive factor when choosing an insurance provider because it suggests that the company is more likely to honor its commitments to policyholders.

In essence, as a policyholder, you can either request a cashless claim or submit a claim form to get your money back from the health insurance company.

Claim Settlement Ratio of Health Insurance

When you're choosing a health insurance company, it is highly important to take the best claim settlement ratio in health insurance into consideration. The highest claim settlement ratio in health insurance basically tells you how good the insurance company is at handling and settling claims. If an insurance provider cannot settle claims properly, buying insurance from them doesn't really serve its purpose.

Some insurance companies even promise to settle claims within a specific timeframe, as long as it's a legitimate claim. For example, Niva Bupa, with the best claim settlement ratio of health insurance, aims to settle health insurance claims within just 30 minutes. These kinds of features make an insurance company more trustworthy for the policyholders.

So, the best claim ratio in health insurance is a key factor because it reflects how reliable an insurance company is, helping people decide which health insurance policy to go for.

What is the Claim Settlement Ratio?

The Claim Settlement Ratio (CSR) is the percentage of claims paid by an insurance company compared to the total number of claims they receive in a year. When you're buying a health insurance policy, CSR is a crucial factor to consider. The whole point of getting an insurance policy is to have yourself covered during medical emergencies. Therefore, checking the health insurance claim settlement ratio is essential before making a decision on which health insurance company to go for.

Top Health Insurance Claim Settlement Ratio in India

Consider selecting an insurance provider based on their excellent health insurance claim settlement ratio for the financial year 2022.

Health insurance claims are of two types, namely Cashless Claim and Reimbursement Claim.

1. Cashless Claim Settlement Method

Cashless Claim Settlement Method is a process where, if you receive medical treatment at a hospital within your insurance network, you can avail a cashless claim. Following the Cashless Claim Settlement Procedure, you don't have to make any payment to the hospital for the provided treatment and medical services. Instead, the insurance company will directly cover the expenses up to the claimed amount. However, please note that your responsibility will be limited to making payments only for co-payments or a chosen sub-limit clause during the initial plan purchase.

2. Reimbursement Claim Settlement Method

When you receive treatment at a hospital that is not in your insurer's network, then you can opt for the Reimbursement Claim Settlement Procedure. In this method, you initially pay the treatment costs at the hospital and later seek reimbursement from your insurance provider, based on the claimed amount. The insurer is responsible for reimbursing the entire claimed amount, taking into account any voluntary or compulsory sub-limits, deductibles, etc., that you selected at the time of purchasing the policy.

5 Key Factors To Understand Claim Settlement Ratio in Health Insurance

The key factors to understand the health insurance claim settlement ratio are as follows:

1. Calculation of the Claim Settlement Ratio

Determining the health insurance Claim Settlement Ratio is a straightforward process and involves a simple calculation. You can find the best claim settlement ratio of health insurance company by using the formula:

Claim Settlement Ratio (CSR) = (Total claims settled or paid)/(Total claims received+Outstanding claims at the beginning of the year)

Some companies with the best claim settlement ratio in health insurance for the Financial Year 2019-20 include IFFCO Tokio Health Insurance, Care Health Insurance, Magma HDI Health Insurance, Oriental Insurance, and more. Due to their high Claim Settlement Ratios, customers tend to trust these insurance companies.

2. Measured For All Company Products

The Claim Settlement Ratio is a measure that applies to all of the products of an insurance company, and not just to health insurance. For instance, the CSR of a life insurance company takes into account the resolution of claims for different plans, ULIPs, etc. For your information, the Claim Settlement Ratio is not given separately for every product.

3. Consistency

Consistency matters the most in the Claim Settlement Ratio. When selecting an insurance company that sells health insurance plans, it is highly crucial to analyse its claim ratio health insurance over the past 5 years. Choosing an insurance provider with a consistently high medical insurance Claim Settlement Ratio indicates that the company can consistently settle claims. And, this makes it a reliable choice for customers.

4. Annual Report by IBAI

The Insurance Brokers Association of India (IBAI) releases an annual report called the General Insurance Claim Insights Handbook for Policyholders. In this report, they publish the medical insurance Claim Settlement Ratios of both public and private insurance companies. This valuable information is accessible to everyone and can easily be found on the official website of IBAI. We recommend you review this report before shortlisting an insurance company for health insurance in India.

5. Total Claims Received By an Insurance Provider

It is important to take into account how many claims an insurance company receives during a given financial year. This provides you with an indication of the company's size and longevity in the industry. Check out InsuranceDekho's Health Insurance Companies section to find insurance providers with the best settlement ratio in health insurance. When buying health insurance in India, knowing which firms have the highest health insurance claim settlement ratio can definitely allow you to make an informed choice.

Documents Required for Health Insurance Claim Settlement

To ensure a successful health insurance claim, you need to have the following documents:

• Original reports of investigation
• Pharmacy bills along with the doctor's prescription
• FIR or post-mortem report if applicable
• Original bills, receipts, and discharge report
• Valid photo ID proof and original hospital bills
• Doctor's report and original consultation notes
• Final hospital discharge summary
• Indoor case papers and a duly filled claim form
• Test results, along with the reports from the attending doctor or surgeon
• Details of the surgery performed, the surgeon's invoice, and the receipt

How to Make a Cashless Medical Insurance Claim?

To make a cashless medical insurance claim, follow these steps, though the process might vary among insurers:

Step 1: Look for a hospital within the insurer's network to avail cashless treatment.

Step 2: Inform the insurance company about your hospitalisation within 24 hours in emergencies (subject to policy terms) and 48 hours before planned admission (subject to policy terms).

Step 3: Visit the network hospital with your cashless card, member ID, or policy number and fill out the pre-authorisation form available at the hospital.

Step 4: The hospital will submit the filled pre-authorisation form to the insurer.

Step 5: The insurer's claim settlement team will review the details and inform the hospital and policyholder about approval or rejection.

Step 6: If the insurer approves the bills, they will directly pay the hospital. And, if rejected, the policyholder is responsible for covering the hospital bill.

It's important to note that these steps provide a general guideline, and specific details may vary based on the policies and procedures of individual insurers. Always refer to your policy documents for accurate information.

Claim Settlement Process for Health Insurance Reimbursement Claims

For health insurance reimbursement claims, the process typically follows these steps, but keep in mind that it might vary among insurance companies:

Step 1: Notify your insurance provider about your hospitalisation within 24 hours for emergency admission and 48 hours before planned admission. The timeline can differ among insurers.

Step 2: Visit the hospital, whether it's a network or non-network one, with your ID, obtain the reimbursement form from the insurer, fill it out, and attach all the required documents with it.

Step 3: After reviewing the documents, the insurer's claim settlement team will send an approval letter to the policyholder. If the claim is approved, the reimbursement is processed within 30 days.

NOTE: The reimbursement timeline may vary among insurers.

Step 4: If the claim is rejected, the insured person is either asked to respond to the insurer's query or provided with the reason for rejection.

Steps to File Health Insurance Claim Form

To file a health insurance claim form, you can follow these steps:

Step 1: Obtain Itemised Receipts

Collect itemised bills that detail all the services provided by your doctor, including the cost of each service and medications. These bills are crucial for claim settlement.

Step 2: Get Your Claim Form

Next, get a copy of the health insurance claim form. You can request it from your insurance company or download it from their official website. The form will furnish information on additional details you might need to provide.

Step 3: Make Copies

Make photocopies of all the documents to prevent any discrepancies during the claim process. Keeping duplicates of the documents also ensures you have a backup in case the original documents are lost.

Step 4: Review and Send the Form

Contact your insurance company and inform them about your intention to file a health insurance claim. Thoroughly review all the paperwork and then submit it to the insurance company. Don't forget to inquire about any additional requirements they might have. Also, ask about the expected response time for your filed claim. If there is no response within the stipulated period, inform the insurance company.

How to Check Health Insurance Claim Status?

To find out the status of your health insurance claim online, follow these steps:

Step 1: Go to the official website of your insurance company.

Step 2: Look for the claim page or section on the website.

Step 3: Enter the necessary details, such as your policy number, customer ID, claim number, etc.

Step 4: Submit the entered details through the website.

Step 5: Once submitted, you will be able to view the status of your health insurance claim.

Common Reasons For The Rejection of Health Insurance Claim

Common reasons for the rejection of health insurance claims by insurance providers include the following:

1. Fraudulent Claims: Claim rejection may occur if the policyholder submits a fraudulent claim.

2. Exclusion from Health Plan: Claims related to exclusions specified in the health plan may be rejected.

3. Expired Insurance Policy: Raising a claim on an expired insurance policy can lead to rejection.

4. Non-Covered Treatment: Claims for treatments not listed under the health plan may be denied.

5. Pre-existing Illness Without Waiting Period Completion: Treatment for a pre-existing illness before completing the waiting period can result in claim rejection.

Claim Repudiation Ratio

A claim repudiation ratio basically gives information regarding the percentage of claims rejected by the insurance provider over the total number of claims received. For instance, a claim repudiation of 30% implies 30 cases over a total of 100 cases are rejected.

Claim Pending Ratio

A claim pending ratio basically gives information regarding the percentage of outstanding claims by the insurer over the total number of claims received. It happens due to the incomplete information provided to the insurer and the time taken by them to validate the incurred costs at the time of hospitalisation.

Incurred Claims Ratio

An incurred claim ratio gives information regarding the net claims settled over the net premium collected by the insurance company in a given year.

CSR or ICR, Which of the Two Should We Look at?

While buying a health insurance plan, you should consider a high claim settlement ratio. However, it should not be the only criteria to choose a good insurance company. Apart from this, you should consider factors like quality of service, premium amount, etc while making a decision.

How do Claims Ratio Data Help me?

Claims ratio data helps in understanding the history of the claim handling procedure of the insurance provider. Also, claims data helps us in comparing and making an analysis of the insurance providers that have been operating for the same time duration. In case you find two insurance companies providing the same benefits, a comparison of the claim settlement ratio of the two companies can help in arriving at a decision.

Does the Claim Settlement Have a Time Limit?

Yes, a health insurance policy in India comes with a time limit in consideration to applying for a claim in order to mitigate the chances of fraudulent activities. An application deadline means less time to falsify the documents.

How to Check the Claim Settlement Ratio of Health Insurance?

You can check the annual report released by the Insurance Regulatory and Development Authority of India(IRDAI) to know the claims of insurance companies.

What is the Claim in Health Insurance?

A claim in health insurance is a request made by the policyholder to the insurance company so as to get the facilities that are mentioned in the health insurance plan.

Things to Remember for a Smooth Health Insurance Claim Process

To ensure a smooth health insurance claim process, remember the following:

• Minimum Hospitalisation Duration: Generally, a minimum hospitalisation of 24 hours is required to make a claim under a health insurance policy. Some day-care procedures may not require 24-hour hospitalisation. Ensure you claim only for expenses covered by your policy.

• Sub-limits on Coverage Features: Certain coverage benefits have limits. For example, there may be restrictions on the type of room or coverage of room rent expenses. Making a claim for expenses not covered by your policy may lead to rejection.

• Waiting Period for Specific Diseases: Be aware of waiting periods, the time you must wait before being eligible to make a claim. Pre-existing diseases and maternity expenses often have waiting periods. You must thoroughly read the policy document to understand waiting periods.

• Co-payments and Exclusions: Understand co-payments, where you and the insurance company share the expenses. Be informed about the co-payment in advance to avoid confusion during claims. Similarly, be aware of exclusions i.e. the expenses not covered by the insurance company. Common exclusions include critical illnesses, mental disorders, abuse of substances, and treatments related to adventure sports.