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 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.
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.
