Health Insurance Claim Settlement Ratio 2023 [Updated]

By Okbima 12 Dec 2023

Health insurance claim settlement ratio is an important parameter for individuals seeking health insurance coverage. It refers to the percentage of policyholders' claims that are successfully settled by the insurance company. A higher claim settlement ratio indicates the insurance company's efficiency in handling and processing claims, providing a sense of security to policyholders. It assures individuals that their claims will be settled without hassle, reducing the financial burden in times of medical emergencies.

What is the Claim Settlement Ratio?

The claim settlement ratio is a measure used by insurance companies to determine the percentage of claims that they have successfully settled against the total number of claims received. It provides an insight into the insurer's ability to honor their policyholder's claims and is indicative of their efficiency and reliability.

A higher claim settlement ratio generally indicates that the insurance company is more likely to settle claims in a timely and satisfactory manner, providing policyholders with the necessary financial support during their time of need.

Importance of the Health Insurance Claim Settlement Ratio (CSR)

Health Insurance Claim Settlement Ratio refers to the ratio of claims settled by an insurance company compared to the total number of claims filed. The CSR plays a significant role in determining the reliability and effectiveness of an insurance provider. Below are some reasons why CSR is crucial in health insurance:

• Trust and credibility: A high CSR indicates that an insurance company is trustworthy and reliable. It demonstrates their commitment to fulfilling their promise of settling claims fairly. Customers are more likely to trust insurers with a high CSR, as it reflects the insurer's ability to meet their financial obligations during a medical emergency.

• Customer satisfaction: Timely settlement of claims is crucial for customers who rely on health insurance to cover medical expenses. A higher CSR implies that the insurance company resolves claims efficiently and without unnecessary delays.

• Financial security: A higher CSR reassures policyholders that the insurer has sufficient financial strength to cover claims. It indicates that the insurer can handle substantial claim amounts and provides policyholders with the financial security they seek.

• Transparency and reliability: A transparent and ethical claims settlement process reinforces the reliability of an insurer. A higher CSR indicates open communication, fair evaluation, and smooth processing of claims.

How to Check the Health Insurance Claim Settlement Ratio?

If you are looking to check the Health Insurance Claim Settlement Ratio, you can refer to the annual reports published by the Insurance Regulatory and Development Authority of India (IRDAI). The IRDAI, as the regulatory body overseeing insurance operations in India, provides comprehensive information on the financial performance of insurance companies.

To check the claim settlement ratio of an insurance company on the IRDAI website, follow these steps:

• Visit the official website of IRDAI: Open your web browser and go to the official website of IRDAI.

• Navigate to 'Public Disclosures': On the main homepage of IRDAI, you will find a menu bar at the top. Hover your cursor over the 'About Us' option, and a drop-down menu will appear. From the drop-down menu, click on 'Public Disclosures'.

• Go to 'Insurance companies': On the 'Public Disclosures' page, scroll down and you will find a section titled 'Insurance companies'. Under this section, there will be a list of all the insurance companies registered with IRDAI.

• Select the insurance company: Locate the insurance company whose claim settlement ratio you want to check. You can either search for the company name using the search bar provided on the page or manually scroll through the list to find it.

• Check the claim settlement ratio: Once you have found the insurance company, click on its name. This will take you to the detailed profile of the selected insurance company. Look for the section titled 'Claim Settlement Ratio' or 'CSR'. The CSR will be displayed as a percentage and will indicate the ratio of claims settled by the company.

List of the Top 10 Claim Settlement Ratios of Health Insurance Companies in India

The List of Top 10 Claim Settlement Ratios of Health Insurance Companies in India showcases the insurance providers that have successfully settled the highest number of claims. This list serves as a valuable resource for individuals looking to invest in health insurance policies and secure reliable coverage.

Name of the Company	Claim Settlement Ratio (2021-22)
Care Health Insurance	100%
Niva Bupa Health Insurance	99.99
Navi Health Insurance CSR	99.99
ManipalCigna Health Insurance CSR	99.90
Aditya Birla Health Insurance CSR	99.41
Liberty General Health Insurance CSR	99.30
Edelweiss Health Insurance CSR	99.26
Star Health Insurance CSR	99.06
Reliance Health Insurance CSR	98.65
HDFC Ergo Health Insurance CSR	98.49

Note: The above-mentioned data has been sourced from the annual report of IRDAI 2021-22.

What is Incurred Claim Ratio (ICR)?

Incurred Claim Ratio (ICR) is a term used in the insurance industry to measure the performance of a health insurance company. It is the ratio between the total value of claims paid by the insurance company and the total premium collected from policyholders in a particular period. ICR helps in evaluating the financial stability and profitability of an insurance company.

A lower ICR indicates that the company has efficiently managed its claims. At the same time, a higher ratio suggests that the company is paying out a significant portion of its premium towards settling claims. A balanced ICR indicates that the insurer is effectively managing risk and maintaining a sustainable business model. It is an important factor for policyholders to consider while choosing an insurance provider.

How to Check the Incurred Settlement Ratio of Health Insurance?

The incurred settlement ratio is an important factor to consider when looking for health insurance plans. It indicates the percentage of claims settled by an insurance company within a given time. To check the Incurred Claim Ratio (ICR) of a health insurance company, you can follow these steps:

• Visit the IRDAI Website: Begin by visiting the official website of the Insurance Regulatory and Development Authority of India, IRDAI.

• Navigate to Public Disclosures: Look for the "Public Disclosures" section on the IRDAI website. This section typically contains various reports and information related to insurance companies.

• Find Annual Reports: Within the Public Disclosures section, locate the annual reports. These reports are comprehensive documents that provide detailed information about the performance of insurance companies, including their Incurred Claim Ratios.

• Select the Relevant Year: Identify the specific annual report for the year you are interested in. The Incurred Claim Ratio is usually disclosed on an annual basis.

• Look for Health Insurance Section: Once you have accessed the annual report, search for the section that pertains to health insurance. This section will contain specific details about the Incurred Claim Ratios for various health insurance products offered by different companies.

• Compare with Industry Averages: Consider comparing the Incurred Claim Ratio of the specific health insurance company with industry averages. This can provide insights into how the company's claims settlement efficiency compares to the broader market.

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Difference Between the Incurred Claim Ratio and Claim Settlement Ratio

The incurred claim ratio (ICR) and claim settlement ratio (CSR) are two different metrics used in the insurance industry to identify the performance of an insurance company. The ICR represents the ratio of the total claims paid by an insurer to the total premiums collected, indicating the insurer's ability to manage claims effectively. On the other hand, CSR refers to the ratio of the number of claims settled by an insurer to the total claims received, reflecting the insurer's efficiency in processing and settling claims.

Feature	Incurred Claim Ratio (ICR)	Claim Settlement Ratio (CSR)
Definition	A measure of an insurer's profitability, calculated as the total amount of claims incurred by the insurer in a given period divided by the total premium earned during the same period.	A measure of an insurer's profitability, calculated as the total amount of claims incurred by the insurer in a given period divided by the total premium earned during the same period.
Focus	Financial performance	Claims processing efficiency
Ideal range	80-100%	95-100%

Required Documents For the Claim Settlement of Health Insurance

When filing an insurance claim, providing the necessary documents to facilitate the settlement process is essential. The required documents typically vary based on the type of insurance claim being made. Below is the list of commonly required documents for health insurance claims.

• Duly-Filled Claim Form: A comprehensive claim form is typically provided by the insurance company. Ensure that all sections of the form are accurately filled out. This form serves as a formal request for claim settlement.

• ID Proof of the Claimant: A valid identification document such as an Aadhar card, passport, voter ID, or any other government-issued ID should be submitted. This helps establish the claimant's identity.

• Medical Certificate: A medical certificate from the treating doctor is crucial. This document outlines the diagnosis, treatment, and other relevant medical details. It serves as evidence of the medical necessity for the claimed expenses.

• Prescription and Cash Invoice from Pharmacy/Hospital: Detailed prescriptions from the treating doctor, along with invoices from the pharmacy or hospital, should be submitted. These documents help establish the need for medication or medical services and provide a breakdown of associated costs.

• Policy Document and Premium Payment Proof: Provide a copy of the insurance policy document and proof of premium payment. This helps verify the policy details and ensures that the coverage is active at the time of the claim.

• Bank Details for Electronic Transfer: To facilitate a smooth settlement process, provide accurate bank details for the electronic fund transfer of the claim amount.

Claim Settlement Process of the Health Insurance Policy

The health insurance claim settlement process is the procedure followed by insurance companies to review and identify the claims submitted by policyholders and then provide payment for eligible medical expenses.

Cashless Claim Process

A cashless claim process is a method where the insured does not need to pay for medical expenses upfront. The insurance company settles the bill directly with the hospital, reducing the financial burden for the insured.

• Claim Intimation: In the event of a medical emergency or planned hospitalization, inform the insurance company as soon as possible. Many insurance providers have a dedicated helpline or an online portal for claim intimation.

• Documents Approval: After the claim intimation, the insurance company will guide you on the documents required for a cashless claim. Submit the necessary documents, including the pre-authorization form, doctor's certificate, hospital bills, and any other relevant records.

• Claim Settlement: Once the submitted documents are reviewed and approved, the insurance company issues a pre-authorization letter to the hospital. This letter allows for cashless treatment up to the approved amount. After the treatment, the bills are directly settled between the hospital and the insurance company.

Reimbursement Claim Process

The reimbursement claim process is a method used by individuals to seek repayment for expenses incurred. It involves submitting documentation and supporting evidence to the appropriate party for review and approval.

• Claim Intimation: Similar to the cashless process, notify the insurance company about the medical treatment or hospitalization. This can usually be done through a helpline or an online portal.

• Documents Approval: Provide the necessary documents to the insurance company, including the claim form, medical certificates, hospital bills, prescriptions, diagnostic reports, and other relevant records. The insurer will review the documents to identify the validity of the claim.

• Claim Reimbursement: Once the documents are approved, the insured individual pays the medical expenses out of pocket. Afterward, submit the original bills and payment receipts to the insurance company for reimbursement. The insurer will verify the documents and process the reimbursement by transferring the approved amount to the insured's bank account.

Reasons for Claim Rejection in the Health Insurance Policy

Claim rejection is a common occurrence in the insurance industry, and it often happens due to various reasons. Below are some of the common reasons for the rejection of insurance claims.

• Non-disclosure of Pre-existing Illnesses: Failure to disclose pre-existing illnesses during the policy application can lead to claim rejection. Insurance companies rely on accurate medical histories to assess risk and determine coverage. If an undisclosed pre-existing condition is discovered, it may result in the denial of the claim.

• Incomplete Forms and Incorrect Information: Submitting incomplete claim forms or providing incorrect information can be the reason for claim rejection. It is essential to fill out all required forms accurately and provide the necessary supporting documentation.

• Wrongfully Withholding Personal Information: Withholding relevant personal information or providing false details intentionally can lead to claim rejection. Insurers rely on accurate information to assess risk and determine coverage.

• Policy Exclusions and Limitations: Claims may be rejected if the circumstances leading to the claim fall under policy exclusions or limitations. Policyholders should thoroughly review their insurance policies to understand what is covered and what is not.

• Lapsed Policy or Non-payment of Premiums: If a policy has lapsed due to non-payment of premiums, the insurance company may reject claims made during the lapsed period. It is crucial to maintain timely premium payments to keep the policy in force.

Conclusion

In conclusion, the health insurance claim settlement ratio plays a crucial role in determining the reliability and effectiveness of an insurance provider. A high settlement ratio signifies that the insurance company is processing and settling claims, which instills a sense of trust and confidence among policyholders. It ensures that individuals can avail the necessary medical treatments without facing financial burdens or delays in reimbursements.

FAQS

How is the Claim Settlement Ratio different from the Incurred Claim Ratio?

The Claim Settlement Ratio (CSR) reflects the percentage of claims settled by an insurer, while the Incurred Claim Ratio (ICR) indicates the proportion of premiums used to settle claims.

How is the Claim Settlement Ratio calculated?

CSR is calculated by dividing the total claims settled by the total claims received and multiplying by 100 to get a percentage.

How long does it take for Insurance companies to settle claims in India?

Claim settlement times vary but typically range from a few weeks to a couple of months, depending on the complexity of the case.

Why do Insurance companies reject claims?

Claims may be rejected due to insufficient documentation, non-disclosure of relevant information, or policy exclusions. Understanding policy terms is crucial.

Where can I find information on the Claim Settlement Ratios of insurance companies?

Find CSR information on the Insurance Regulatory and Development Authority of India (IRDAI) website or check insurer annual reports and official websites.

What is considered the best claim settlement ratio for a Health Insurance company?

A high CSR indicates better claim settlement performance. Look for a ratio above 95% for a health insurance company, reflecting reliable claim settlements.

Do I always need to choose a company with a high claim settlement ratio?

While a high CSR is indicative of a reliable insurer, consider other factors like coverage, premiums, and customer service for a comprehensive assessment.

How do I apply for an insurance claim?

Inform the insurer promptly, fill out the claim form accurately, submit the required documents, and follow the prescribed process outlined in your policy document.

What are the two most common mistakes made while submitting a claim?

Common mistakes include incomplete documentation and delayed claim reporting. Ensure all required documents are provided promptly to avoid delays.

What documents must I submit to file a claim with the insurance company?

Generally, documents include the filled claim form, medical certificates, bills, and other relevant records. Refer to your policy document for specific requirements.

Where can I get the claim form and list of documents required to file a claim?

Obtain the claim form from the insurer's website or customer service. The list of required documents is typically available in the policy document or on the website.

What is a settlement letter in an insurance claim?

A settlement letter outlines the details of the approved claim, including the amount to be paid and the terms of settlement. It serves as an official confirmation.

What is a cashless claim settlement in an insurance claim?

In a cashless settlement, the insurer directly settles the medical bills with the hospital, sparing the policyholder from making upfront payments for covered expenses.

Can CSR be more than 100%?

No, CSR cannot exceed 100%. It represents the percentage of claims settled out of the total claims received, and 100% signifies all claims settled.

What is the best Claim Settlement Ratio for health insurance?

Look for health insurance companies with a CSR above 95% for a strong track record in settling claims promptly and efficiently.

How to choose a company with a top Claim Settlement Ratio in health insurance?

Research insurer reviews, check IRDAI reports, and compare CSR along with other factors like network hospitals, coverage, and premiums before choosing.

Which health insurance company has the best Claim Settlement Ratio?

Check the latest IRDAI reports or visit the official websites of health insurance companies to find the most up-to-date Claim Settlement Ratios.

Can I pay my health insurance premium online?

Yes, most insurers offer online premium payment options through their websites or mobile apps for convenient and secure transactions.

Should I consider the reputation of the insurer while choosing an insurance company?