Health Insurance Claim Settlement Ratio

Decoding the Health Insurance Claim Settlement Ratio for Better Decisions

The claim settlement ratio is a factor in choosing the correct insurance company. Analysing the top 10 claim settlement ratio health insurance companies in India will help you find the correct company that suits you. Then, you may wonder what the claim settlement ratio of health insurance is.

What is the Health Insurance Claim Settlement Ratio?

Claim Settlement Ratio could be termed as the ratio of total claims settled to the total claims filed multiplied by 100. That is, the claim settlement ratio of health insurance is calculated by (total claims settled / total claims filed) multiplied by 100.
You may also want to know the claim settlement ratio published by IRDAI for health insurers. The health insurance claim settlement ratio is termed the total number of claims settled in a year divided by the total number of claims in a year, which is multiplied by 100.

Significance of Claim Settlement Ratio in Health Insurance

The claim settlement ratio in health insurance makes the customer understand how much a customer can depend on the insurer when it comes to covering medical expenses. So, you could consider an insurance company trustworthy and reliable if it has a high settlement ratio.

How do I claim Health Insurance?

Know how to claim health insurance so that your health insurance claim process might be easier. Here are the steps to claim the health insurance.

Informing your insurer (insurance company) of the claim as soon as possible after receiving treatment
Gather all the relevant documents, like bills, discharge summaries, prescriptions, and medical reports.
You may submit the documents to your insurer or the Third-Party Administrator (TPA), depending on the type of claim.
You may have to wait for the decision, as your insurer will review your claim and process it as per the terms of your policy.

Process in the Health Insurance Claims Settlement

Your work is to analyse the claim ratio of health insurance of different companies to choose the right one. The health insurance claim settlement ratio could help you choose the correct company, but after that, you may wonder how health insurance claims are settled.

Once you inform the insurance company within 24 hours of hospitalisation, you have to submit the health insurance claim form with the other necessary documents. The insurance company in which you bought the policy will send an authorisation letter to that network hospital. Then, your insurance company will settle the bill directly with the hospital.

The claim settlement process of health insurance involves two types, namely cashless claims and reimbursement claims.

1) Cashless Claim

Cashless claims for treatment at the network hospitals associated with the insurance company can be made. Here is the process involved in filing a cashless claim with your insurer:

Claim Intimation's first step involves informing the insurer(or TPA) through a call or email.
Document approval involves the hospital examining the health card and identity of the policyholder and submitting the pre-authorisation form to the insurer/TPA.
Claim Settlement involves the insurer/TPA sharing the approval (if everything is found in order). After the treatment is completed, the insurer will settle the treatment bills directly with that network hospital.
But there are some exclusions, like the expenses that won't be paid by the TPA/insurer, which have to be settled only by the patient/family directly at the hospital.

2) Reimbursement Claim

A reimbursement claim filing can be made by the claimant if he/she selects to get treatment at hospitals networked with the insurance company. However, the policyholder has to pay the incurred costs out of pocket, after which they can file a claim with the insurer for the reimbursement process.

Here are the steps involved in filing a reimbursement claim.

Claim intimation involves informing the insurance company about your hospitalisation as per your insurer's timeline.
You need to submit the documents along with the claim form. Document approval involves the insurance company checking all the submitted documents.
Claim reimbursement involves settlement of the claim as per the terms and conditions of the policy after the completion of all the formalities. Later, the amount will be transferred to the claimant's registered bank account.

Documents Necessary for Claim Settlement

The following is the list of documents you must have to submit for filing a health insurance claim:

Claim form that is duly filled.
A medical certificate issued by your doctor and authorised by the hospital is attached with the diagnosis report.
Claimant's identity proof.
Prescription and cash invoice received from pharmacy/hospital.
FIR (if it was an accident).
Bank Details

Tips about Health Insurance Claim

You must consider claim settlement ratio of health insurance companies to choose the best one. However, after selection, some tips help for a hassle-free process.

Here are the tips to have a health insurance best claim settlement ratio:

More than once, read your policy thoroughly. Make sure that your policy's terms and conditions include the claim process and necessary documents.
Identify the network hospitals that are covered by your policy so that you can choose the hospital needed for your medical emergency. You should receive treatment only at a network hospital for cashless claims.
Make sure that you submit the documents within the time limit.
You can consider an appeal if your claim is denied. For that, follow the instructions in your policy to file an appeal.
Avoid rejection by not hiding any information, such as pre-existing conditions, and keep your documents safe.

Star Health is one of the health insurance company pronounced by the people for its health insurance claim ratio. With the highest claim settlement ratio in health insurance, it is among the top claim settlement ratio health insurance companies in India. (Source: The Hindu BusinessLine)

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FAQ

How do I know the health insurance claim status?

To check the status of your health insurance claim, you can visit your insurance company's website or mobile app and enter your policy or claim number: <ul><li>Visit your insurance company's website. </li><li>There, click on the health insurance page.</li><li>Choose the "Claims" or "Claim" icon.</li><li>Now, select "Track Claim Status" or an option similar to it.  </li><li>Just type your policy number, claim number, customer ID, mobile number, or name.</li><li>Click "Submit".</li><li>You may see the status of a health insurance claim on the display.</li></ul> However, the option to check the health insurance claim status may differ for different companies.

What is the best health insurance claim settlement ratio?

A claim settlement ratio of above 80% is the best health insurance claim settlement ratio. Generally, a good incurred claim ratio must fall between the range of 75% and 90%.