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Health Insurance Claim Settlement Ratio

Importance of Claim Settlement Ratio while Buying Health Insurance

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I

93%

Claim Settlement Ratio (OND 2018)

II

7900 +

Network Hospitals across 500 cities

III

400 Lacs+

Lives covered

What is Health Insurance Claim Settlement Ratio?

Health insurance claim settlement ratio is a metric that is generally used to rate health insurance company. If it settles a high percentage of medical insurance claims that have been intimated, it has a higher claim settlement ratio. Simple and quick claim procedures and a large number of network hospitals ensures higher claim settlement ratio.

Claims settlement ratio is the ratio of the number of claims settled by an insurer in a year to the total number of claims made. It serves as a metric to rate insurers and also helps the policy buyers to compare policies and select the best insurance policy based on this number. The higher health insurance claim settlement ratio guarantees higher chances of getting an easy settlement on your claims. Thus, it is advised that you should ensure that your insurer has a good claim settlement ratio before opting for a health insurance policy

The standardization of health insurance claim settlement is done by IRDAI(Insurance Regulatory and Development Authority of India). The IRDA publishes the claim settlement ratios annually in the first month of every year. The health insurance claim ratio is often the most important factor that is taken into consideration by individuals when they look for a health insurance plan.

Claim Settlement Ratio

If you are planning to opt for a health cover, it is imperative that you find out about the claim settlement ratio of health insurance companies that will help you choose the best health insurer.

It is the yardstick to assess the chances of claim settlement by the health insurance provider. A higher claim ratio assures the higher possibility of hassle-free claim settlement. Else, your purpose of investing in health insurance plans will be defeated if your claims are denied or delayed. Hence, you need to ensure that you should opt for an insurer with a good 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 this means that it is able to settle 80 out of 100 claims.

Claim Settlement Ratio = (Total Claims Settled)/(Total Reported Claims + Outstanding Claims at 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 are yet to make a decision 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 is a ratio of two numbers.

Rank

Insurer

Claim Settlement Ratio

Claims Available

March 31, 2019

March 31, 2018

September 30, 2016

March 31, 2019

1

Religare Health

92.58%

89.69%

85.15%

7,00,596

2

Manipal Cigna

89.43%

84.91%

81.68%

1,53,782

3

Apollo Munich

84.10%

84.08%

78.43%

3,45,967

4

Max Bupa

83.92%

88.06%

72.74%

94,174

5

Star Health

78.15.%

79.34%

60.94%

8,15,584

6

Aditya Birla Health

72.80%

85.34%

-

62,306

Source: IBAI Claims Handbook

Here's what Moneycontrol Says:

When it comes to health insurance, Religare Health has 93% claim settlement ratio. The health insurer handled 7,00,596 claims in the financial year and settled almost 93 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. Religare Health Insurance has the best insurance claim settlement ratio in health insurance i.e. 93%.

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 the Religare Claim Settlement Ratio indicates reliability, which is often the most important factor while choosing an insurance company.

>> Check: What is No Claim Bonus

Health Insurance Claim Settlement Process

Here are the steps that must be followed to avail a cashless health insurance claim.

  1. The first step is to find a Religare Health Insurance network hospital in the city where you want to get treated.
  2. Inform Religare Health Insurance within 24 hours of an emergency hospitalization or 48 hours before a planned hospitalization.
  3. When you visit any of the network hospitals, be sure to carry the cashless treatment card, or at least know the member ID or policy number.
  4. The card or the policy number must be shown in the insurance section of the hospital.
  5. A pre-authorization form will be given, and you will have to fill in the relevant details.
  6. The pre-authorization form will then be sent to Religare Health Insurance.
  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 Religare Health Insurance will bear the medical expenses. If it is rejected, then the policyholder is expected to bear the cost.

Cashless Insurance Claim Settlement

A cashless insurance claim settlement is a facility in which 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. In most cases, the cashless health insurance claim is provided only at network hospitals that have 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 Religare Health Insurance 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 will also require a legitimate discharge certificate and a discharge summary from the hospital before you can claim your insurance. The insurance company will carefully examine your submitted bills and hospital certificates before granting you a reimbursement.

The health insurance claim process for reimbursement settlements is illustrated below:

  1. Insurance Claim intimation: Inform Religare Health Insurance 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 to Religare Health Insurance
  3. Health Insurance Claim Processing: The team will review the case and documents that were submitted, and the claim will be approved or rejected. In case it is rejected, the reason for rejection will be clearly stated.

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. This is why it’s advisable to understand about the claim settlement ratio of health insurance companies and opt for the health covers from the insurer that has a higher claim settlement ratio. Read below why it is so important?

4 Reasons Why Health Insurance Claim Settlement Ratio is Important

  • Assures Great Value Products
  • Reflects Efficiency
  • Show Reliability
  • Indicate Sound Financial Health

Assures Great Value Products

The ideal health insurance claim settlement ratio lies between 80-90 %. Companies with a claim settlement ratio between 80-90% have great value 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 get the benefits under a health insurance claim.

Reflects Efficiency

You should also check the average claim settlement time of the health insurer. 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 for the insurer 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 the creditworthiness of your health insurance provider.

Indicate Sound Financial Health

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

Takeaway

Therefore, 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 floater or family health insurance plans offered by Care Health Insurance (formerly Religare Health Insurance) that has that has a consistent claim settlement ratio. With the Religare Claim Settlement Ratio of 93%, you can rest assured about hassle-free timely claim settlement.

FAQS

name text">Where can I get claim forms and list of documents required for submission?

You can get the claim forms and list of documents for submission by visiting the official website of Care Health Insurance. The forms are available under the ‘Claims’ section in 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 making a claim 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 hospitalisation, the insured person must inform the company within 24 hours of admission. If it is planned hospitalization, then in such cases the insured person should notify the insurer 48 hours prior to the admission.

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