Health Insurance Claim Settlement Ratio
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Health Insurance Claim Settlement Ratio
In the present day, there are an array of health insurance companies and the products they offer, but which insurer should you choose? Do you know of any health insurance company that offers credibility independent of its brand image? Is there a health insurance provider who can help you to overcome your worst health-related nightmare, and the financial chasms that result from it the most?
In order to make this decision, you will need to consider a number of factors. However, there is one significant factor that plays an important role in this matter, which is the Claim Settlement Ratio (CSR). There are many factors that go into this analysis, such as the reputation of an organization, the ability to pay health insurance claims, the capacity for general risk management on the part of the insurer, and many more.
Health insurance claim settlement ratio
When deciding on a health insurance provider, it is essential to consider the insurer’s claim settlement ratio as it is one of the most important factors to take into account since it reveals the insurer’s ability to handle claims in a timely manner.
In the event that the business cannot satisfy the claims, then the entire purpose of having health insurance is lost. There are many insurance providers who promise to resolve claims within a given timeframe if they are legitimate and there is no evidence of fraud involved with the claim.
As a result of these types of factors, the customer is more likely to trust an insurance company. This means that the claim settlement ratio of an insurance company, or CSR, is a good indicator of the company’s dependability and it helps policyholders make decisions about buying a new health insurance policy as they prepare for doing so. But before jumping the gun, let us understand some other concepts like the Incurred Claim Ratio.
Difference between Claim Settlement Ratio and Incurred Claim Ratio:
- Claim Settlement Ratio:
The number of health claims that health insurance firms (individually) resolve over the course of a fiscal year is shown by their claim settlement ratio. Based on the ratio of claims settled to claims received, the computation is made. CSR data is not published by the IRDAI in their Annual Report. - Incurred Claim Ratio:
The amount spent by the insurer to settle claims is shown by the incurred claim ratio. It simply contrasts the company’s profits from new business premiums with the expenditures associated with claims. The ICR data is published by the IRDAI in its annual report.
How is the Claim Settlement Ratio (CSR) Calculated in Health Insurance?
(Number of claims settled/Number of claims received) * 100 is the claim settlement ratio.
Let’s use an illustration to help you understand:
The claim settlement ratio equals 95% if an insurance firm receives 500 claims per year and settles 475 of them. However, the remaining 5% are known as rejected claims.
However, when understanding the concepts of Claim Settlement, you need to understand how soon the claims are being settled, so that the basic purpose of opting for a health insurance plan, i.e. to provide financial assistance when in medical emergencies, gets fulfilled. This is why IRDA publishes the data of % of claims settled within 3 months, between 3-6 months, etc.
Here is the list of the claims settled by the insurer in terms of ageing of the claim.
| No. | Insurer | Age Analysis of Number of Claims Paid (%) | |||||
| < 3months | 3 monthsto 6 months | 6 monthsto <1 year | 1 yearto <3 years* | 3 yearsto <5 years** | > 5years | ||
| Private Sector Insurers | |||||||
| 1 | Acko General Insurance Ltd. | 97.20 | 1.67 | 0.80 | 0.33 | – | – |
| 2 | Bajaj Allianz General Insurance Co. Ltd. | 96.59 | 2.62 | 0.25 | 0.39 | 0.07 | 0.09 |
| 3 | Cholamandalam MS General Insurance Co. Ltd. | 93.23 | 4.06 | 1.39 | 0.92 | 0.27 | 0.13 |
| 4 | Edelweiss General Insurance Co. Ltd. | 97.26 | 2.07 | 0.62 | 0.06 | – | – |
| 5 | Future Generali India Insurance C. Ltd. | 96.01 | 2.05 | 0.89 | 0.59 | 0.22 | 0.24 |
| 6 | Go Digit General Insurance Ltd. | 96.09 | 2.62 | 0.87 | 0.41 | 0.02 | – |
| 7 | HDFC ERGO General Insurance Co. Ltd. | 98.49 | 1.03 | 0.22 | 0.20 | 0.04 | 0.02 |
| 8 | ICICI Lombard General Insurance Co. Ltd. | 97.07 | 1.69 | 0.59 | 0.37 | 0.12 | 0.17 |
| 9 | IFFCO Tokio General Insurance Co. Ltd. | 89.38 | 6.43 | 2.26 | 1.17 | 0.42 | 0.34 |
| 10 | Kotak Mahindra General Insurance Co. Ltd. | 96.90 | 2.24 | 0.57 | 0.27 | 0.03 | – |
| 11 | Liberty General Insurance Ltd. | 97.30 | 1.27 | 0.61 | 0.65 | 0.14 | 0.03 |
| 12 | Magma HDI General Insurance Co. Ltd. | 92.34 | 5.09 | 1.54 | 0.74 | 0.20 | 0.10 |
| 13 | Navi General Insurance Ltd. | 99.99 | 0.01 | – | – | – | – |
| 14 | Raheja QBE General Insurance Co. Ltd. | 93.30 | 4.88 | 1.37 | 0.40 | 0.05 | 0.00 |
| 15 | Reliance General Insurance Co. Ltd. | 98.65 | 0.65 | 0.23 | 0.26 | 0.11 | 0.12 |
| 16 | Royal Sundaram General Insurance Co. Ltd. | 95.95 | 1.26 | 0.80 | 1.59 | 0.22 | 0.18 |
| 17 | SBI General Insurance Co. Ltd. | 95.04 | 2.55 | 1.67 | 0.67 | 0.04 | 0.03 |
| 18 | Shriram General Insurance Co. Ltd. | 85.23 | 2.81 | 2.63 | 4.85 | 1.80 | 2.67 |
| 19 | Tata AIG General Insurance Co. Ltd. | 93.55 | 3.97 | 1.90 | 0.45 | 0.07 | 0.06 |
| 20 | Universal Sompo General Insurance Co. Ltd. | 95.77 | 2.78 | 0.97 | 0.38 | 0.08 | 0.02 |
| 21 | National Insurance Co. Ltd. | 86.28 | 8.76 | 2.46 | 1.52 | 0.56 | 0.41 |
| 22 | The New India Assurance Co. Ltd. | 92.93 | 4.30 | 1.56 | 0.75 | 0.21 | 0.25 |
| 23 | The Oriental Insurance Co. Ltd. | 90.18 | 5.68 | 2.17 | 1.44 | 0.29 | 0.24 |
| 24 | United India Insurance Co. Ltd. | 97.25 | 2.01 | 0.51 | 0.17 | 0.03 | 0.02 |
| 25 | Aditya Birla Health insurance Co. Ltd. | 99.41 | 0.26 | 0.05 | 0.28 | – | – |
| 26 | Care Health Insurance Ltd. | 100.00 | 0.00 | 0.00 | – | – | – |
| 27 | ManipalCigna Health Insurance Co. Ltd. | 99.90 | 0.06 | 0.02 | 0.02 | – | – |
| 28 | Niva Bupa Health Insurance Co. Ltd. | 99.99 | 0.01 | 0.00 | – | – | – |
| 29 | Reliance Health Insurance Ltd. | 76.36 | 7.27 | 7.27 | 5.45 | 3.64 | – |
| 30 | Star Health and Allied Insurance Co. Ltd. | 99.06 | 0.70 | 0.20 | 0.05 | 0.01 | – |
How does the data of Claim Settlement Ratio of less than 3 months affect it?
By looking at the claim settlement ratio, prospective buyers can determine how well each insurer handles the claims that have been filed against it.
- In order to calculate the claim settlement ratio, one must keep in mind that the entire product line of the insurance company is included in the calculation. As a consequence, determining the unique ratio for each health insurance plan becomes a difficult task.
- In order to achieve a higher settlement ratio for health insurance claims, the business must have strong financial stability and the ability to pay out claims on behalf of its clients.
- You should also check to see whether the insurer offers you the greatest “value for money” advantages you are looking for before you decide to buy a health insurance policy and compare the prices of different insurers before buying one.
There are times when a claim might be necessary, so it is important to take into account your policy’s exclusions when the need arises. There are several provisions in your insurance plan that need to be taken into account, including network hospitals, waiting periods, and sub-limits.
Why do policyholders give CSR data so much importance?
Claim Settlement Ratio would enable them to select an appropriate health insurance plan and the best health insurance company.
Here are a few explanations for why the claim settlement ratio is so crucial:
- Reflects the health insurance company’s reputation for reliability:
As a prospective policyholder, you may have questions such as “Will this insurer settle my claims?” which is one of the most important questions you should ask before choosing a health insurance provider.
For customers, this is one of the most important factors in determining whether or not a health insurance provider can be trusted in their health care needs. A Claim Settlement Ratio (CSR) will be able to tell you how many claims your insurance company has resolved over the course of a year, thus highlighting the credibility of the company. - Ease of claim:
Most people fret about opting for health insurance plans because of anticipated difficulty in the claim. So, if the claim settlement ratio of the insurer less than 3 months is very high, it provides a sense of comfort in the minds of the prospective policyholder that their claim procedure with this insurer would also be similar and easy. - Reveals information about a company’s consistency throughout the lawsuit settlement procedure:
Health insurance companies cannot be uneven in their reimbursements when using CSR as a record. For all of the claims raised, they must maintain their claim settlement strategy and guarantee; otherwise, the ratio will reflect this.
This indicates that policyholders have the crucial financial certainty of a payout regardless of whether they are looking for a:
1. In a partner hospital, the cashless system
2. Payment method in a hospital that is not a partner
3. Provides an excellent way to compare different health insurers.
Consider that you are looking for a health insurance plan that you may transfer or that you can buy fresh.
Therefore, you may use our health insurance comparison tool or talk to an insurance counsellor. The Claim Settlement Ratio is now one of the factors that will stand out as a metric of comparison in each of these scenarios.
Disadvantages of Claim Settlement Ratio in a Health Insurance Plan:
No doubt, CSR is an important metric that can be used to filter out insurance companies from which you can purchase policies, but it should not be the only factor considered. It is important to note that this ratio does not indicate a few important things:
- The time taken in settling the claim:
As much as CSR reveals how many claims have been resolved by the insurance company over the years, it does not provide a way for the policyholder to estimate how long it may take for the claim to be resolved once the claim has been filed. There are TATs and regulations provided by the IRDAI for claim settlement. This is why the data of the percentage of total claims settled within 3 months is more important than the standalone data of Claim Settlement of the Insurance Company. - The financial capabilities of a company:
An insurance company’s claim settlement ratio is a measure of how frequently claims are settled by the insurance company, from the point of view of the insurer.
It must be noted, however, that the report does not reveal the financial standing of the insurance company, which will allow it to continue offering its services, uphold its social responsibility, and remain one of the most reputable providers of health insurance in the market.
Unfortunately, a health insurance provider’s claim settlement ratio does not indicate what portion of the claim amount was settled by the provider.
Let’s take the case of a demand for INR 5 lakhs. However, because of several restrictions or exemptions, the health insurer only paid out INR 3 lakhs. The CSR would indicate that this case had a resolved claim, but it would not indicate that the insurer had made a copayment.
Seeing this data blindly would mean that choosing a health insurance provider is based on more factors than just the ratio. Instead, consider the following when selecting your health insurance company:
a. Claim Settlement Ratio within 3 months
b. Process of Claim Settlement
c. Incurred Claim Ratio
d. Extensive Product Portfolio
e. A big list of Network Hospitals, etc.
A few Tips to Buy the Best Health Insurance in India:
Instead of focusing just on the Claim Settlement data of health insurance companies, follow the steps to get optimal health coverage for yourself and your family.
Step 1: Opt for the “right” amount of coverage:
Buying a health insurance policy is a significant decision that requires you to evaluate the type of coverage that is provided. As a general rule, when we talk about coverage, we mean the medical costs that will be covered by your policy, such as maternity, ambulance, daycare, pre and post-hospitalization expenses, and so on.
Choose a plan that covers the medical needs of your family as well as your own, and ensure that it provides the appropriate coverage for you.
If you choose a plan that provides more coverage than you require, you will have to pay a higher premium because the price will increase. If you choose to add riders to your plan, you can adjust it to meet your needs and make it more convenient for you.
Pro Tip: As a thumb rule, your coverage should be at least 50% of your family’s annual income.
Step 2: Check if you can opt for Family Floater Plans:
Rather than buying individual health insurance policies for each member of the family, you might be better off choosing a family floater plan if you need coverage for the entire family.
The cost of family floater plans tends to be lower than the cost of availing individual health insurance for each member of the family.
Further, not everyone falls ill at the same time, so any member of the family may be able to use the sum insured that is available as a floater, as needed, in the event of a medical emergency.
Pro Tip: Do not include your parents in the same family floater coverage as you and your family, especially if they are senior citizens. There are 3 reasons for the same:
- There are specifically designed health insurance plans for senior citizens which cater to their needs and your requirements for health insurance could be quite different from theirs.
- If your parents have any pre-existing ailment, it is best to declare the same right at the outset so that you can opt for coverage with PED coverage benefits after a certain waiting period.
- Senior citizens could get hospitalised more often. So, if they are in the same family floater plan, you would lose out on your no-claim bonus if there are frequent claims.
Step 3: Cost Benefit Analysis,
i.e. Appropriate premium for the desired cover that is affordable also:
When it comes to choosing a sum insured when buying medical insurance, make sure that you select the amount that truly fits your needs.
It is likely that your premiums will rise significantly if you choose a higher sum insured. Instead, if you choose a lesser amount of coverage than you really need, it might not be sufficient to cover all your expenses for medical emergencies, which means that you will have to pay out of pocket once your claim has been settled.
Pro tip: The other option is to choose a basic plan with a smaller coverage amount and add a top-up insurance plan to your purchase as an alternative. The top-up plan will provide you with additional coverage in the event that the maximum amount of coverage in your basic plan has been reached.
Step 4: Look for long-term health care benefits:
especially post-retirement:
Make sure the health insurance plan you choose can be renewed forever and you do not lapse your plan in order to get continuity benefits. This is critical as you would need your health insurance plan more in your older days.
Pro tip:
Buying a fresh health insurance plan in your retirement years could be quite a challenge especially if you already have any PED by then. Thus, ideally, you should opt for a sufficient health insurance plan which can be continued forever. Of course, you can choose to port your plan to any other plan/ insurer as per your change in requirements from time to time, provided the plan has been continuously renewed on time, without any lapse.
Step 5: Check the ENTIRE claim process:
And not just the Claim Settlement Ratio:
Claim settlement experience is the most important reason for opting for a health insurance plan. So, that experience counts a lot more than the CSR data itself and that is why checking the data for claims settled within the first 3 months is more relevant.
Step 6: Examine the Network of Authorized Hospitals:
Pick an insurance provider when you’re ready to get medical insurance that offers a large network of hospitals. If you have a cashless facility, you do not need to worry about settling the bill out of your own pocket as it would be taken care of by the insurer.
As a result, you want to select a plan from a health insurance company that offers a network of hospitals in your area.
Step 7: Opt for plans without sub-limits or co-pay to reduce your out-of-pocket expenses:
When selecting a health insurance plan, do remember to consider the provisions of sub-limits as well as co-payment terms and conditions. The co-payment amount is the portion or the percentage of the claim amount that you agree to pay at claim settlement, while sub-limits refer to the coverage limit on particular covers.
Pro Tip: Try opting for a health insurance plan without any sub-limit clause or provision for co-payment in order to avoid any financial stress during claim settlement and reduce your overall out-of-pocket expenses.
Step 8: Compare and choose the plan that best suits your needs:
One of the best ways to find the best health insurance is to compare the different plans based on their coverage, perks, and costs in order to make an informed decision. Using a comparison tool will help you find the plan that has the best coverage at the most affordable price for you.
Step 9: Check the waiting period:
Especially if you have any pre-existing disease (PED):
The PED waiting period is a crucial factor to take into account when selecting a health plan. After the PED waiting period, the insured may submit a claim for pre-existing conditions. Depending on the plan, the PED waiting time typically ranges from 2 to 4 years. You must choose a health plan with a shorter PED waiting time as a result.
Pro Tip: Opt for a health insurance plan early in your life so that you exhaust all the waiting periods before you might actually need to file a claim!
Step 10: Start your health insurance coverage NOW:
Don’t procrastinate and wait to find the “BEST” health insurance plan as your requirements could keep changing with your age, life stage, lifestyle, etc.
Pro Tip: You can change/ port your health insurance plan at any time if you find a better plan. But remember to pay your premiums on time, so that your policy doesn’t lapse and you can avail of continuity benefits.
Conclusion
A policyholder must submit a request to their insurer through the health insurance claim settlement process in order to use the medical treatments covered by their health plan. The policyholder can use this to either obtain a cashless treatment or to be reimbursed for already-used medical services. And before buying any plans one must compare different plans and policies offered by different companies.
Frequently Asked Questions
The claim settlement ratio measures how many raised claims were satisfied by an insurance provider compared to all claims raised for the insurer within a given fiscal year.
As it displays the percentage of settled claims in a fiscal year, the claim settlement ratio reveals the level of trust that may be placed in an insurance company's hands.
While the incurred claim ratio, which compares the number of claims paid out in a year to the premiums collected, reveals the company's long-term financial health.
The claim settlement ratio of a company will allow you to determine how well the company handles claims so that you don't run into any problems in the future when you need to file a claim. It is important to take into account the claim settlement ratio of an insurance company when purchasing health insurance plans online in order to determine how reliable the insurer is.
But to understand the ease of claim, check the process and the percentage of total claims settled by the insurer within 3 months.
By phone or email, policyholders may provide their insurance company feedback. For the same, they can speak with their customer service staff.
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