Claim Settlement Ratio

Health Insurance Claim Settlement Ratio (CSR) is used to determine a company’s ability to settle claims against the number of requested claims in a financial year. Every year, the Insurance Regulatory and Development Authority of India (IRDAI) publishes the claim settlement ratio of every health insurance company in its annual report.

Evaluating the claim settlement ratio before buying a health insurance plan is a good idea, as it reflects the efficiency, reliability, and financial health of an insurer.

In this article, we will tell you everything about the claim settlement ratio of Care Health Insurance.

What is the Claim Settlement Ratio?

The Claim Settlement Ratio of a company refers to the claims settled by a company against the total claims filed during that financial year. For example, if a company settled 90 claims out of 100, its CSR would be 90%.

The simple formula for calculating the CSR is:

(Total Claims Settled) / (Total Reported Claims + Outstanding Claims at the beginning of Year - Outstanding Claims at the End of Year)

Care Health Insurance Claim Settlement Ratio

As per IRDAI, Care Health Insurance's Claim Settlement Ratio is 92.77% in the first quarter of 2025. The company claims to settle cashless claims within 2 hours. To date, the company has settled over 25 lakh claims. This figure shows that the company understands the importance of quick claim settlement and ensures to support you at the time of medical and financial need.

What is the Claim Settlement Process of Care Health Insurance?

Care Health Insurance works in a very transparent and systematic manner to clear claims. Following is the claim settlement process of Care Health Insurance:

Cashless Claim Procedure

• In the case of an emergency or planned hospitalization, inform the insurer within 24 hours or 48 hours of hospitalization.
• The nominee of the policy has to fill and submit the pre-authorization request form to the hospital's insurance/TPA desk.
• The hospital will then send all the documents to the company, i.e., Care Health Insurance, for verification.
• After reviewing all your documents, the claim management team will send an approval letter to the hospital.
• The hospital will proceed with the cashless treatment of the insured member.

Note: If the cashless claim is rejected, the insured member can initiate the treatment and file for a reimbursement claim after discharge.

Reimbursement Claim Procedure

• In the case of an emergency or planned hospitalization, inform the insurer within 24 or 48 hours of the hospitalization.
• The insured has to submit the duly filled reimbursement claim form to the insurer along with the required supporting documents such as:
  • Original duly completed and signed claim form
  • Valid photo ID proof
  • Medical practitioner's referral letter advising hospitalization
  • Medical practitioner's prescription advising drugs/diagnostic tests/consultation
  • Original bills, receipts, and discharge card from the hospital/medical practitioner
  • Original bills from pharmacy/chemists
  • Original pathological/diagnostic test reports/radiology reports and payment receipts
  • Indoor case papers
  • First Information Report (FIR), final police report, if applicable
  • Post-mortem report, if conducted
  • Any other document as required by the company to assess the claim
• The company will check and review the documents.
• If the claim is approved, the company will transfer funds to your registered bank account.

Conclusion

Care Health Insurance has a claim settlement ratio of 92.77% for Q1 2025, demonstrating its commitment to settling over 25 lakh claims, often within 2 hours for cashless cases. Understanding their transparent claim process, whether cashless or reimbursement, and preparing all necessary documentation is crucial for policyholders to ensure a smooth experience during medical emergencies.