Health Insurance Claim Settlement is the process of claiming your health insurance policy benefits from the insurance company. When you buy a health plan, it comes with a cover in the form of a sum insured. The sum insured is utilized to provide financial aid in case of emergency/accidental hospitalization/medical treatment costs.
How do you utilize your sum insured? By making a claim directly with your insurer. Upon successful registration of your claim, the insurer will accordingly reimburse the cost of medical treatment incurred.
For example, Mr. A met with an unfortunate accident for which he was admitted to the hospital for 48 hours. The cost of medical treatment, doctors’ fees, and the hospital bill came up to Rs. 1 lakhs. Since Mr. A has a comprehensive health insurance coverage policy of up to Rs. 5 lakhs sum insured, he can quickly settle this claim with his insurance company. Under this process, the amount of Rs. 1 lakh will be compensated to Mr. A by his insurance provides, as per the policy cover.
As mentioned above, the two most common methods of making a claim are via cashless or reimbursement mode.
Here is a list of the best health insurance providers in India, along with their claim settlement ratio and incurred claims ratio.
Claim Settlement Ratio is nothing but the percentage of insurance claims paid out or settled during a financial year. It is the number of claims settled to the number of claims received. It cannot be more than 100%. For example, if an insurer has a claim settlement ratio of 95%, it means that it has paid out 95 out of 100 claims.
Incurred Claims Ratio, on the other hand, is the proportion of claims paid out to the amount of premium received during a financial year. ICR can exceed 100% because there can be more claims than premiums in a single financial year.
| Insurance Company | Health Claim Settlement Ratio FY2020 | No of Claims for Processing |
|---|---|---|
| New India Assurance | 100.83% | 5459068 |
| Oriental Insurance | 104.97% | 5633511 |
| National Insurance | 103.30% | 2531045 |
| United India Insurance | 104.24% | 6652619 |
| Iffco Tokio General Insurance | 95.66% | 929589 |
| HDFC Ergo General Insurance | 69.01% | 2069142 |
| Bajaj Allianz General Insurance | 81.96% | 2789992 |
| Royal Sundaram General Insurance | 63.55% | 467728 |
| TATA AIG General Insurance | 66.61% | 1083129 |
| Universal Sompo General Insurance | 76.68% | 167241 |
| ICICI Lombard General Insurance | 69.90% | 1788734 |
| SBI General General Insurance | 76.20% | 283195 |
| Reliance General Insurance | 89.36% | 1948028 |
| Cholamandalam MS General Insurance | 40.67% | 271595 |
| ManipalCigna insurance | 61.64% | 153782 |
| Max Bupa | 83.92% | 94174 |
| Star Health | 65.91% | 815584 |
| Aditya Birla Health Insurance | 49.08% | 62306 |
Source: IBAI Claims Handbook 2020 (moneycontrol.com/news/business/companies/highest-claims-settlement-record-is-your-insurer-on-this-list-4827211.html)
| Insurer Name | Incurred Claim Ratio for 2018-19 | Grievances Solved |
|---|---|---|
| HDFC ERGO | 62% | 96.73% |
| Star Health and Allied | 63% | 98.96% |
| Future Generali India Insurance Company | 73% | 99.73% |
| Bajaj Allianz | 85% | 99.78% |
| ManipalCigna Health Insurance | 62% | 99.58% |
| National Insurance | 107.64% | 97.07% |
| IFFCO TOKIO | 102% | 98.47% |
| New India Assurance | 103.74% | 99.94% |
| Oriental Insurance | 108.80% | 73.83% |
| Reliance General Insurance | 94% | 98.49% |
| SBI General Insurance | 52% | 96.01% |
| Max Bupa Health Insurance | 54% | 99.3% |
| Care Health Insurance (formerly Religare) | 55% | 99.30% |
| Universal Sompo Insurance | 92% | 98.2% |
Disclaimer: The information given above has been sourced from the official website of the respective insurance providers. The ICR has been sourced from the annual report filed by IRDAI for FY 2018-19. (Last updated on 09.11.2020) Plus, get complete details on each of the plans mentioned above on Coverfox.
There are two types of claim settlement options:
A cashless claim option can only be availed if you are admitted to a network hospital, as mentioned in the policy document. Your policy document has a list of network hospitals in your city of residence. With the cashless mode, you need not pay a single amount from your wallet. The insurer will cover the entire cost of hospitalization and medical treatment. All you need to do is furnish your cashless health card to the third party administrator.
Under this option, you will be required to pay the hospital bill and cost of medical treatment to the hospital, immediately post-treatment or before discharge. Then you need to file for claim reimbursement directly with your insurer. The insurer will reimburse the cost of treatment as per the policy wordings.
All the listed documents should be original:
Claim settlement process via cashless mode/pre-planned:
Yes, here are the instances under which your claim can get rejected:
In Simple Words,
When you are looking to buy a health plan, ensure that you go for a company with a high claim settlement and incurred claims ratio.
