Health Insurance Claim Settlement Ratio
  • Explore Claim Settlement Ratio
  • What is ICR?
  • Claim Settlement Process
Health Insurance Claim Settlement Ratio
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Health Insurance Claim Settlement Ratio

Health Insurance is a modern-day necessity. Many of us who want the best health insurance plan for ourselves and our families are sure to gather every piece of information regarding the big purchase. One can only hope to get financial support from their health insurance providers when a medical need arises.

However, do you know how reliable your health insurer is regarding claim settlements? How long does it take for your insurer to settle claims? Or How many claims have they rejected in the past years? The next question is which health insurance has the best claim settlement ratio and how to check it. Let us find out the answers to all these questions.

What Is Claim Settlement Ratio In Health Insurance?

The claim settlement ratio is the percentage of several claims an insurance company settles within a specific period against the number of claims received. In simple words, a claim settlement ratio of 92% for a health insurance provider means that for every 100 claims filed, 92 were settled successfully within a fixed period.

traordinary Facts

The Insurance Regulatory and Development Authority of India (IRDAI) published its latest annual report for the financial year of 2023-24. In a recent change in trend, the regulator has started publishing only the Incurred claims ratio (ICR) of general insurers rather than the claim settlement ratio, as in previous years.

Claim Settlement Ratio Of Health Insurance Companies In India

CompanyNetwork HospitalClaim Settlement Ratio (FY 2022-23)Incurred Claims Ratio (FY 2023-24)
Star Health Insurance14,000+99.21%66.47%
HDFC Ergo16,000+98.59%87.70%
ICICI Lombard10,800+98.53%70.79%
IFFCO Tokio7,000+90.65%86.33%
Kotak Mahindra11,200+97.61%65.56%
Aditya Birla11,000+99.01%68.31%
Care Health24,800+100%57.69%
ManipalCigna8,500+99.96%63.78%
Niva Bupa10,000+100%59.02%
Acko General10,500+97.68%69.57%
Bajaj Allianz18,400+93.54%73.80%
Cholamandalam12,000+93.63%73.66%
Zuno10,000+98.54%82.64%
Future Generali8,43094.98%71.85%
Godigit8,800+96.83%70.32%
Liberty5,00097.46%75.29%
Magma8,400+94.72%79.88%
Navi General12,000+95.13%52.40%
Raheja QBE5,000+97.30%77.91%
Reliance Health10,000+98.75%81.06%
Royal Sundaram11,800+96.17%77.62%
SBI General16,625+96.47%85.90%
Shriram General9,500+86.86%63%
Tata AIG General11,000+95.46%71.43%
Universal Sompo4,000+91.58%81.74%
National Insurance3,000+91.31%95.90%
New India3,000+90.73%97.36%
Oriental3,500+91.62%98.89%
United India14,000+91.10%96.50%

How To Check Claim Settlement Ratio Of Health Insurance Companies?

To get insights on each company’s health insurance claim settlement ratio, visit PolicyX and check out our data labs section. Each year, the governing body (IRDAI) publishes the statistics of Indian health and life insurance providers for the financial year which are published on our website for a better idea of Indian health insurance claim settlement status.

How Is the Health Insurance Claim Settlement Ratio Calculated?

The formula given below is how CSR is calculated for general insurance companies

Claim Settlement Ratio = (Total number of claims settled/Total number of claims received) x 100

Let us understand this with an example,

An insurer received 2 Lakh claims in a year and settled 1,98,000 claims the same year. The claim settlement ratio for the same would be

CSR for the health insurer = (1,98,000/2,00,000) x 100 = 99%

Incurred Claims Ratio: How Is It Different From Claim Settlement Ratio?

The claims settlement ratio is the percentage of the total claims paid by the insurance company in a particular period. However, the incurred claim ratio, on the other hand, is the percentage of the total claim amount paid against the total premium collected in a given time.

In simpler words, a 90% incurred claim ratio means that for every Rs 100 of collected premiums, the insurance company spends Rs 90 on claims within the year.

Health Insurance Claim Settlement Process

There are 2 types of health insurance claim settlement processes you must know of:

Cashless Claim SettlementReimbursement Claim Settlement
Fill out the pre-authorized form available at the TPA desk of the hospitalSubmit your claim form along with all necessary documents to your health insurer
You will receive an acknowledgement message from your insurerGet the discharge summary and approval letter from the hospital management
Submit all your documents and answer all enquires to your health insurerRespond to all queries raised by your health insurance provider
Once verified your health insurer will settle the claim with the hospital directly.Once all details are verified, your health insurer will reimburse your medical bills in your account as per the policy sub-limits.

Claim Settlement Ratio: An Important Indicator

Evaluating and examining which health insurance has had the best claim settlement ratio in previous years will help you make an informed purchase decision. How?

  • Helps you understand how many claims were rejected by the insurer
  • Helps you compare all health insurance providers in the market
  • A consistently upward track of a health insurer is a promise that it will help you financially in times of medical emergencies
  • A higher CSR indicates financial support and mental peace

Documents Required For Claim Settlement

Below are the documents that you need to submit for the claim request for your health insurance:

  • Pre-authorized claim form
  • ID proof
  • Address proof
  • Discharge summary and diagnostic reports
  • FIR (In case of an accident)
  • Prescription and cash invoice from pharmacy/hospital

Additional documents may vary from insurer to insurer and may vary depending on your medical case.

Concluding Note

Selecting an ideal health insurance provider is tricky when you have multiple options in the market. This is why relying on insurance advisors and gaining insights into factors like the highest claim settlement ratio in health insurance is important.

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Health Insurance Claim Settlement Ratio: FAQs

1. What is the Claim Settlement Ratio in health insurance?

Claim Settlement Ratio in health insurance indicates how many claims an insurer has settled against the number of claims received during a financial year. A high claim settlement ratio showcases that the company can offer you cashless treatment in times of medical need.

2. What is the highest claim settlement ratio in health insurance?

As per the IRDAI reports, the highest claim settlement ratio has gone to 100% for Niva Bupa and Care Health Insurance for FY 2022-23.

3. What is considered the best claim settlement ratio?

A good claim settlement ratio is anywhere above 80%.

4. What documents do I need for claim settlement?

You will need identity proof, address proof, discharge summary, diagnostic reports, pharmacy bills, and pre-authorized forms.

5. How much time does it take for a cashless claim settlement?

A cashless claim is settled before the discharge. However, a reimbursement claim settlement may take 15 days depending on the insurer.

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Simran Kaur Vij

Written By: Simran Kaur Vij

Simran is an insurance expert with more than 4 years of experience in the industry. An expert with previous experience in BFSI, Ed-tech, and insurance, she proactively helps her readers stay on par with all the latest Insurance industry developments.