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Health Insurance Claim Settlement Ratio

  • Avail Tax Benefit under Section 80D
  • Coverage for Pre & Post hospitalization
  • Annual Health Checkup for All Insured Members
  • Comprehensive Coverage Including AYUSH Treatment
19000+

Cashless Healthcare Providers^^

95.2%

Insurance Claim
Settlement Ratio

247

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    What is Health Insurance Claim Settlement Ratio?

    Health insurance claim settlement ratio (CSR) is a metric used to rate health insurance companies. It is ascertained in the form of a percentage and represents the number of claims settled by a health insurance company against the total number of claims filed in a year. It helps buyers to compare health insurance companies and select the best health insurance policy based on the ratio. In addition, 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 considered by individuals when they look for a health insurance plan. A higher claim ratio assures a 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 is the claim settlement ratio of health insurance companies Calculated?

    As we all know, the claim settlement ratio refers to the percentage of claims settled by the health insurance company against the total claims received in a year. So, 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, 2020

    1

    Care Health Insurance

    95.22%

    92.58%

    89.59%

    85.15%

    1,074,232

    2

    Manipal Cigna

    85.68%

    89.43%

    84.91%

    81.68%

    225,847

    4

    Max Bupa

    89.26%

    83.92%

    88.06%

    72.74%

    147,718

    5

    Star Health

    78.27%

    78.15.%

    79.34%

    60.94%

    1,143,291

    6

    Aditya Birla Health

    70.32%

    72.80%

    85.34%

    -

    178,584

    Source: IBAI Claims Handbook

     

    Here's what Moneycontrol Says:

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

    Key Benefits of Claim Settlement Ratio of Health Insurance

    • It helps you understand the insurer's liability.
    • It gives financial security to the family in the absence of the insured.
    • 80% and above claim settlement ratio can help you ascertain that you can depend upon the company to provide the promised claim to the nominees of the insured.
    • Customers can easily compare between two or more insurance companies.
    • A good CSR gives customers a sigh of relief while buying insurance.

    However, 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 indicates our reliability, which is often the most vital factor while choosing a health insurance company.

    >> Check: What is No Claim Bonus

    Health Insurance Claim Settlement Process

    As a policyholder, you can claim in below two ways:

    Cashless Health Insurance Claim Settlement

    A cashless insurance claim settlement is a facility where the health insurance company itself settles the medical bill with the hospital. Thus, 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 process for cashless claim settlement is as follows:

    • Admission at the listed network hospital is required to avail cashless hospitalization facility
    • Fill the pre-authorization form available at the hospital's insurance / TPA Desk
    • Send it to our claim management team
    • You will get an approval letter after verification
    • For further queries from the claim management team, you or the hospital staff must respond to the
    • File for a reimbursement claim if your cashless request gets rejected.

    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 is as follows:

    • Submission of claim form along with required documents, as per the policy terms & conditions
    • Approval letter sent by the claim management team
    • Insured to respond to the query raised by the claim management team
    • We will communicate the reason in case of rejection

    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 policy 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. This is because 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. Therefore, opt for the company 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. For example, 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.

    What is a Good Claims Settlement Ratio?

    It is always necessary to understand the importance of good claims settlement ratio to be safe and secure in the future. 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. The company ensures their services whenever in the time of dire need and provides us best possible help.

    Policyholders should be aware of the ratio their health insurance company provides in case of any contingency. Claim settlement ratio should be evaluated after seeing the history of the past 5 years of the company. If there happens to be inconsistency in the CSR, you better give it another thought.

    A good claim settlement ratio of a company can always vouch for your financial security. CSR is the most strengthening aspect of an insurance company that makes it unique.

    Care health insurance has 95.2% of CSR for the year 2019-20.

    *Always consider your insurance provider by being thoughtful about the steadiness of the CSR and its year wise improvement.

    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 about Claim Settlement Ratio

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    Q. 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.

    Q. Why is it necessary to submit all the records/documents as required by the company?

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

    Q. What is the duration 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.

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

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

    Q. How much time does it 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.

     

    ^^Number of Cashless Healthcare Providers till 25th March 2022.

    ^Annual premium for product 'Care' and 'Care Shield (add on)' is Rs. 6160/-(excl. GST) for 1 adult falling under the age bracket 05-24 years, 1 Adult 18-24 age group 3 Yr with NCB Super (Add-on).

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