What is Group Insurance Claim Settlement Ratio?

CSR is the proportion of claims settled out of the total number of claims received by the insurance company. Claim settlement ratio is one of the vital factors that a customer should look out for while purchasing a group health insurance policy. It is because the main objective of purchasing a group health insurance plan is to get a claim whenever required.

Health Insurance Company Claim Settlement Ratio In India

Here is the claim settlement ratio of some of the group health insurance-providing companies in India.

Disclaimer: Policybazaar does not rate, endorse,or recommend any particular insurance company or their products.

Types Of Group Health Insurance Claim Settlements

There are two types of group health insurance claim settlements. They are as follows:

Cashless

When you get treatment in one of the network hospitals and raise a claim, then the insurer steps up to make the payment of the hospital bills, medicines, etc. on your behalf. This method is called cashless claim settlement where you don’t have to pay out of pocket except for the deductibles.

Reimbursement

When you do not get the treatment in a network hospital and raise a claim, then you have to make the payment for the hospital bills, medicines, etc. This method is called reimbursement claim settlement where the insurer reimburses the amount paid by the insured within the period decided by the IRDAI. They just cut out deductibles amount and transfer the rest of the amount.

5 Points To Understand Group Health Insurance CSR

To understand the group insurance claim settlement ratio, you need to understand these 5 points.

1. Annual Report by IBAI

Insurance Brokers Association of India publishes the Claim settlement ratio of all the companies in its Handbook that includes claims insights for the policyholders. It is suggested to go through this handbook before choosing a buy from any particular insurance company. You can find it on the official website of IBAI.

2. CSR Calculation

It is easy to understand how the claim settlement ratio is calculated.

CSR = Total Claims Paid/Outstanding claims + Number of Claims Received

3. Consistent

The insurance company has to be consistent with the percentage of claims settled every financial year. Consistency in the claim settlement ratio makes the insurance company stand out from the list of insurance providers.

4. Measured for All Types of Products

Claim settlement ratio is calculated considering all types of insurance policies whether health, car, two-wheeler, home, etc. The calculation of CSR is not just based on the health insurance claims settlements.

5. Claims Received By The Insurer

The number of claims received by the insurer is another way of judging an insurance company before purchasing a group health insurance plan. You can learn about the reputation of that company as to how new or old the company is and how many claims has the company settled out of a received number of claims.

Group Health Insurance Claim Settlement: Documents Required

To raise a claim, you need to provide a set of documents to initiate the claim settlement process of a group insurance policy. The documents required are as follows:

1. Doctors prescriptions, investigation reports
2. Medical store bills
3. Copy of FIR if any
4. Copy of post mortem report if any
5. Original hospital bill
6. Discharge report
7. Receipts, original bills
8. Valid ID Proof
9. Consultation notes of the treating doctor
10. Duly filled claim form
11. Type of operation performed along with surgeons bill receipt

Steps to Make Cashless Group Health Insurance Claim

Here are the steps that you can follow to make a cashless claim.

Step 1: first of all you need to find a network hospital nearby and get the treatment done.

Step 2: Then you can inform your insurer and tell them about the hospitalization within 24 hours of a medical emergency and 48 hours before you plan to admit the patient to a network hospital.

Step 3: Fill in the documents and then show your cashless card along with the policy number at the hospital insurance desk.

Step4: Fill in the pre-authorization form provided to you at the hospital

Step 5: The hospital sends the pre-authorization form to the insurance company for the claim settlement.

Step 6: The insurance company will set a team of inspectors who will examine the details provided by the insured and then inform the insured about the approval or rejection of the raised claim.

Step 7: Once the claim gets approved, the insurance company pays the hospital on behalf of you. However, if the insurance company rejects the claim then the insured has to pay for it.

Steps to Make Reimbursement Claim In Group Health Insurance

Here are the steps that you have to follow to raise a reimbursement claim.

Step 1: Inform the insurer about the medical emergency within 24 hours of admission to the hospital.

Step 2: Visit the hospital and ask for the reimbursement claim form from the insurance desk.

Step 3: Fill in the claim form and submit it along with the documents required.

Step 4: Make the payment.

Step 5: A team of inspectors will examine the details and then approve or reject the claim.

Step 6: If the insurer approves the claim, then the amount is reimbursed within a month.

Step 7: if the insurer rejects the claim, then the insurance company provides a reason for rejection to the insured.

Reasons Behind Rejection of Group Health Insurance Claim

Here are some of the reasons behind the rejection of the claim raised in a group health insurance policy.

1. If the insurance company detects a fraud activity
2. If the claim raised by the insured is an exclusion in the policy
3. If the insurance policy expires
4. If you get treatment for pre-existing disease and haven’t completed the waiting period

Type of Claim Ratios To Know About

1. Claim Repudiation Ratio

The claim repudiation ratio refers to the number of claims rejected out of the number of claims received by the insurance company in a financial year.

2. Incurred Claim Ratio

Incurred claim ratio refers to the net claims settlement out of net premium collected in a financial year by the insurance company.

3. Claim Pending Ratio

Claim pending ratio is the number of claims pending to get settled out of total claims received in a financial year by the insurance company.

Claim Settlement Ratio Or Incurred Claim Ratio

While purchasing a group health insurance policy, it is recommended to look for a company that has a high settlement ratio. However, your selection should not be entirely based on this factor only. You should always consider the scope of coverage, premium amount, service quality, etc. to make the right decision.

How Is CSR Helpful?

The claim settlement ratio of a company is the percentage of claims settled by the insurance company in a financial year. With this information along with the history of claim settled you can judge the performance of the insurance company and compare different insurance companies while purchasing group health insurance policy.

How To Check CSR?

You can check the claim settlement ratio of all the insurance companies on the official website of the Insurance Regulatory & Development Authority of India.

Remember These Point For Smooth Claim Settlement

Take care of the following for smooth claim settlement.

• Minimum 24 Hours of Hospitalization: The insured has to be hospitalized for a minimum of 24 hours to be eligible to raise a claim and get the coverage benefits under the group health insurance plan. Apart from this, several daycare procedures that do not require hospitalization so make sure that you raised the claim for the daycare procedures covered under your group health plan.
• Sub-limit: Several coverages have a sub-limit. You can raise a claim for such perils only up to the specified amount in the insurance policy.
• Co-payment: Co-payment is a clause between the insurer and the insured where both of them partially pay for the medical expenses incurred in treatment.