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  • Top Insurance Companies
  • Plans As Per Your Need
  • Types of Claim Settlement
  • Documents Required
  • How To Make Claim
icon Health Insurance icon Health Insurance Claim Settlement

What is Health Insurance Claim Settlement?

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.

Top Health Insurance Companies in India for 2023

Here is a list of the best health insurance providers in India, along with their claim settlement ratio and incurred claims ratio.

Q. What is CSR/ICR?

  • 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 Health Insurance 100.83% 5459068
Oriental Health Insurance 104.97% 5633511
National Health Insurance 103.30% 2531045
United India Health Insurance 104.24% 6652619
IFFCO TOKIO Health Insurance 95.66% 929589
HDFC ERGO Health Insurance 69.01% 2069142
Bajaj Allianz Health Insurance 81.96% 2789992
Royal Sundaram Health Insurance 63.55% 467728
TATA AIG Health Insurance 66.61% 1083129
Universal Sompo Health Insurance 76.68% 167241
ICICI Lombard Health Insurance 69.90% 1788734
SBI Health Insurance 76.20% 283195
Reliance Health Insurance 89.36% 1948028
Cholamandalam MS Health Insurance 40.67% 271595
ManipalCigna Health Insurance 61.64% 153782
Niva Bupa Health Insurance 83.92% 94174
Star Health and Allied Insurance 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)

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.

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What are the Types of Claim Settlement Options?

There are two types of claim settlement options:

Cashless Claim Settlement Option

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.

Reimbursement Claim Settlement Option

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.

What are the Documents Required for Claim Settlement Process?

All the listed documents should be original:

  • Claim application Form - Duly filled and signed
  • Doctors’ prescription
  • Treatment papers
  • investigation/diagnostic reports/X-Ray
  • Original medical bills and scripts
  • Invoice for medicines
  • Hospital discharge card
  • Copy of FIR in case of an accidental emergency
  • Copy of Health Card
  • Cancelled Cheque
  • KYC - PAN card and Hospital Registration Card
  • Consultant’s certificate with diagnosis (including the date when symptoms first occurred)
  • Relevant Investigation reports (Radiology, Pathology, etc) confirming the diagnosis
  • Certificate from attending doctor/physician stating the condition of the patient
  • How to Make a Health Insurance Claim?

    Claim settlement process via cashless mode/pre-planned:

    • Visit the network hospital of your choice
    • Submit your cashless card at the TPA
    • Fill the Cashless Request Claim Form and submit the same to the TPA
    • Ensure that you have a relevant photo ID and policy number
    • Submit the relevant documents required for treatment
    • The TPA will coordinate with your insurer for a pre-authorization form
    • Post verification, the insurer will grant the precision for covering the cost of treatment meant
    • Make sure you take all the records of your treatment and hospital bills In the reimbursement mode case, you will be required to clear the hospital bill from your own pocket. Later, when you are discharged, you will have to file a reimbursement claim with your insurer along with the relevant documents. Post submission, your insurer will process the claim accordingly and reimburse the treatment cost straight to your account.

    Can My Claim Get Rejected?

    Yes, here are the instances under which your claim can get rejected:

    • Any fraudulent claims
    • Claim under an expired policy
    • Treatment which is not covered under the scope of cover
    • Treatment within the waiting period
    • All types of general and standard exclusions

    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.

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