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Health Insurance Claim Settlement Ratio

Importance of Claim Settlement Ratio while Buying Health Insurance

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I

95.2%

Claim Settlement Ratio (OND 2018)

II

8350+ +

Network Hospitals across 500 cities

III

400 Lacs+

Lives covered

What is the Health Insurance Claim Settlement Ratio?

Health insurance claim settlement ratio (CSR) is a metric used to rate health insurance companies. It is the ratio of the number of claims settled by the health insurance company in a year to the total number of claims made. It helps buyers to compare health insurance companies and select the best health insurance policy based on the ratio. The higher health insurance claim settlement ratio guarantees higher chances of getting an easy settlement on your claims. Thus, it is advisable to ensure that your insurer has a good claim settlement ratio before opting for a health insurance policy.

The standardization of health insurance claim settlement was done by IRDAI(Insurance Regulatory and Development Authority of India). It publishes the claim settlement ratios annually in the first month of every year. The health insurance claim ratio is often the most important factor taken into consideration by individuals when they look for a health insurance plan. A higher claim ratio assures the higher possibility of hassle-free claim settlement. Else, your purpose of investing in health insurance plans will defeat if your claims are denied or delayed. Hence, you need to ensure that you should opt for a company like us with a higher claim settlement ratio.

How to Calculate Health Insurance Claim Settlement Ratio?

The claim settlement ratio refers to the total number of claims settled by the health insurance company. For instance, if an insurer has an 80% health insurance claim settlement ratio, it has settled 80 out of 100 claims.

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

Consider an example where a health insurance company receives 1000 claims. Out of these, it has paid 973 claims. Of the remaining 27, it has rejected 16 and is yet to decide on 11 claims. The claim settlement ratio, in this case, would be 973/1000 = 97.3%.

The health insurance claim settlement ratio is always calculated as a percentage and has no units since it has two numbers.

Rank

Insurer

  

Claim Settlement Ratio

Claims Available
March 31, 2020

March 31, 2019

March 31, 2018

September 30, 2016

March 31, 2019

1

Care Health Insurance

 95.2%

92.3%

89.69%

85.15%

7,00,596

2

Manipal Cigna

 85.68%

89.43%

84.91%

81.68%

1,53,782

4

Max Bupa

 89.26%

83.92%

88.06%

72.74%

94,174

5

Star Health

 78.27%

78.15.%

79.34%

60.94%

8,15,584

6

Aditya Birla Health

 70.32%

72.80%

85.34%

-

62,306

Source: IBAI Claims Handbook

Here's what Moneycontrol Says:

When it comes to health insurance, Care Health Insurance has a 95.2% claim settlement ratio. The health insurer handled 7,00,596 claims in the financial year and settled almost 95.2 percent of them.

For the health industry as a whole, the claims settlement ratio stood at 85.18 percent for the year ended March 31, 2019. This rose from 80.77 percent in the year-ago period.

Key Benefits of Claim Settlement Ratio

Medical insurance claim settlement ratio allows a person to understand the history of the insurer, and how well it can handle claims. It can act as an important factor deciding factor. If two products from different health insurance companies have similar benefits, but one of them has a 90% health insurance claim settlement ratio while the other has just 60%, then a customer is more likely to choose the former.

However, one must keep in mind that the health insurance claim settlement ratio is not a perfect indicator of how good an insurance company is. Consistency of the insurance claim settlement ratio over the years must also be taken into consideration. A consistent claim settlement ratio like we have indicated our reliability, which is often the most important factor while choosing a health insurance company.

>> Check: What is No Claim Bonus

Health Insurance Claim Settlement Process

Here are the steps to avail of a cashless health insurance claim:

  1. The first step is to find a Care Health Insurance network hospital in the city where you want to get treated.
  2. Inform our customer support team within 24 hours of an emergency hospitalization or 48 hours before a planned hospitalization.
  3. When you visit any network hospitals, be sure to carry the cashless treatment card and member ID or policy number.
  4. Inform the TPA desk at the hospital and our customer support team about the hospitalization. 
  5. Submit the pre-authorization form with relevant details.
  6. Send the form to our claim management team.
  7. Our team will review the received details, and based on the claim details; they will approve or reject the claim.
  8. If the claim is approved, then we will bear the medical expenses. In case of cashless claim denial, you can refile for reimbursement.

Cashless Insurance Claim Settlement

A cashless insurance claim settlement is a facility where the health insurance company itself settles the medical bill with the hospital. You are spared the burden of paying the bills and waiting for reimbursement. The cashless health insurance claim facility is available only at network hospitals having a tie-up with the health insurance company. A cashless insurance claim settlement also saves the hassle of submitting all the relevant medical bills along with the discharge summary.

The claim process for cashless treatments is as illustrated below:

  • Claim intimation: Inform our customer support team within 24 hours of an emergency hospitalization or 48 hours before a planned hospitalization.
  • Initiate pre-authorization process: Fill in the pre-authorization form and hand it over to the hospital’s insurance desk.
  • Processing a request for pre-authorization: the in-house medical team will review the documents and either approve or reject the claim.

Reimbursement Health Insurance Claim Settlement

Reimbursement claim settlements will generally require you to pay all hospital expenses and collect all related medical bills ranging from ambulance cost to treatment cost. You also need a legitimate discharge certificate and a discharge summary from the hospital before claiming your insurance. Our claim management team will carefully examine your submitted bills and hospital certificates before granting you a reimbursement.

The health insurance claim process for reimbursement settlements is as follows:

  1. Insurance Claim intimation: Inform our support team within 24 hours of an emergency hospitalization or 48 hours before a planned hospitalization.
  2. Initiate Health insurance claim process: The claim form must be filled with the required details and sent along with the documents.
  3. Health Insurance Claim Processing: The team will review the case and documents submitted, and the claim will be approved or rejected. In case of rejection, we will communicate the reason.

Why is Claim Settlement Ratio Important while Buying Health Insurance?

When you are investing in a health insurance policy, that means you are looking for protection and financial security against future medical emergencies. That is why it's advisable to understand the claim settlement ratio and opt for the health covers from the company with a higher claim settlement ratio. Read below why it is so important?

Assures Great Value Products

The ideal health insurance claim settlement ratio lies between 80-90 %. Companies with a claim settlement ratio between 80 and 90% have great value for healthcare products and good to go for investment. They offer a wide range of health insurance products with maximum coverage and a quick settlement claim process. Therefore, it's advisable to opt for the companies with a higher claim settlement ratio to benefit from a health insurance claim.

Reflects Efficiency

You should also check the average claim settlement time by the health insurance companies. It should be a period between 20-30 days. This time frame reflects that the health insurance company is good at settling the claim efficiently. You should go to a company like us that offers you the claim settlement within a short period.

Show Reliability

New insurers generally have lower claim settlement metrics than already existing companies. So it's better to check its claim history before you buy a health insurance plan. You can ask about the number of claims settled so far, unsettled claims, and claims that are on hold. Thus, with the insurance claim settlement ratio, you can cross-check your health insurance provider's creditworthiness.

Indicate Sound Financial Health

A good settlement report shows that the health insurance company has sound financial health, profits, offers qualitative health insurance plans, and meets customers' expectations. It is trustworthy to invest your hard-earned money and protect your future.

Takeaway

Whenever choosing a health insurance company, it’s always recommended to do a thorough search on its claim settlement ratio. It gives you an idea about its financial history and reliability. You can check the comprehensive health insurance plans offered by Care Health Insurance (Formerly Religare Health Insurance), the best health insurance company in claim settlement. Our CSR is 95.2% that ensures hassle-free claim settlement to our customers.

FAQS

Where can I get claim forms and a list of documents required for submission?

You can get the claim forms and a list of documents for submission by visiting Care Health Insurance's official website. The forms are available under the 'Claims' section on the website.

Why is it essential to submit all the records/documents as required by the company?

Policyholders are required to submit relevant documents when claiming as it helps the company to assess and process the claims of customers in a quick and hassle-free manner.

What is the time frame within which the claim must be reported to the company?

In case of emergency hospitalization, the insured person must inform the company within 24 hours of admission. If it is a planned hospitalization, the insured person should notify the insurer 48 hours before the admission.

How many health insurance claims can a policyholder request in a year?

A policyholder can request an unlimited number of claims depending upon the scope of coverage and limit of sum insured.

How much time does an insurer take to settle the health insurance claim?

If it is a cashless claim, we settle your bills at the time of discharge from the hospital. If it is reimbursement, you have to submit the required documents within 15 days from the discharge. We will process the claim after approval.

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