Claim Settlement Ratio is defined as the total claims paid, out of the total claim requests received by an insurance company. It is one of the critical elements of any insurer. Every customer has always been concerned about the insurance providers whether they will settle the insurance claim or not. Hence, it is crucial to understand the following three types of claim ratios.

What are the different types of Claim Ratios?

  1. Health Insurance Claim Settlement Ratio
  2. Health Insurance Claim Repudiation Ratio
  3. Health Insurance Claim Pending Ratio

1. Health Insurance Claim Settlement Ratio

It represents the reliability of an insurance provider in settling claims. If an insurance company receives a claim request, and it gets paid, the claim settlement ratio would be excellent. A higher value of settlement ratio means that most claims are getting settled. Below is an easy formula to calculate the claim settlement ratio of health insurance companies

Claim Settlement Ratio = Total claims settled/Total claim requests received

2. Health Insurance Claim Repudiation Ratio

Claim repudiation ratio is the percentage of the claims rejected by the insurer. The following is the formula to calculate claim repudiation ratio:

Claims Repudiation Ratio= (Number of claims rejected/ Total number of claim requests received) %

Untimely requests, false claims, the coverage that is not included in the policy, etc., are the typical reasons for claim rejection.

3. Health Insurance Claim Pending Ratio

Claims pending ratio gives the number of outstanding claim requests that have neither rejected nor accepted. Below is the formula to calculate the claims pending ratio:

Claims Pending Ratio= (Remaining claim requests/ total number of claim requests) %

Health claimscan go in the pending state because of several reasons, such as missing documents from customer's end, insurers taking time to validate the hospital expenses, etc.

How to Check the Claim Ratio of Health Insurance Companies?

Every first month of the calendar year, the IRDAI makes a ratio of all the insurance companies in India and makes it public. While buying health insurance, a policyholder should not just consider the settlement ratio but should also check the number of claims the company has received. Read on further to know how to claim health insurance.

How to Claim Medical Insurance?

The health insurance claim process involves the following steps that you need to take care of:

  1. Reporting: A policyholder can place claim requests at branches, central offices, online, and through customer care helpline, email, or SMS.
  2. Processing: The processing of health claims should be hassle-free and quick. The lesser the turnaround time for mediclaim reimbursement process, the better it is for a company's overall reputation.
  3. Settlement: The final step of the mediclaim reimbursement process, i.e. settlement, is when all the required documents are evaluated, and the health insurance claim is approved.

How Cashless and Reimbursement Claims differ?

Cashless Claims

Cashless health insurance claims allow you to get admitted in any of your insurer's network hospitals, without paying anything from your pocket. For availing this facility, the policyholder needs to provide the policy documents to the hospital during admission. The hospital sends the medical expenses directly to the insurance company. For claims in the case of planned hospitalisation, it would be best to contact the insurance company before the admission.

Reimbursement Claims

You cannot opt for the cashless facility if you undergo treatment in a non-network hospital. You can opt for a reimbursement claim once clear the hospital bills from your pocket. For reimbursement claim requests, you are required to submit all the treatment-related documents, such as reports, prescriptions, and bills to your insurance provider. The insurer will then evaluate your documents and process your reimbursement claim if it is approved.

What Steps to Follow to Avoid Health Insurance Claim Rejection?

  1. It would be best if the policyholder discloses correct and complete information to the insurance company.
  2. The policyholder should fill the insurance application form on his own and not seek insurance agent's help for it. This is because the agent may not be aware of the policyholder's personal information and may miss out something essential.
  3. During the free-look period, it should be great if the policyholder thoroughly checks the policy's documents and sees if all the terms and conditions are as desired. Note that the policyholder can return the policy and ask for a refund if there is any discrepancy in the policy's conditions.
  4. The last step is to inform the policy's nominee the moment policy becomes active.

Statistics on Claim Settlement Ratio of Health Insurance Companies

The following information shows the claim settlement ratio of the top 10 health insurance providers. It would be best to check this data before choosing an insurance company.

  1. Bajaj Allianz: 93.95%
  2. Bharti Axa:77.78%
  3. Apollo Munich: 84.08%
  4. Iffco Tokio: 92.88%
  5. Reliance: 75.76%
  6. HDFC Ergo:82.99%
  7. National Insurance: 78.52%
  8. Star Health: 79.34%
  9. Care Health: 89.59%
  10. Max Bupa: 88.06%