Health Insurance Claim Settlement Ratio

Claim Settlement Ratio or CSR in health insurance is the ratio of the number of claims settled against the total number of claims filed during a financial year. It helps in weighing the capability of the insurer to handle customer’s claims. For example, if 100 claims were registered during a financial year, and the insurer was able to settle 94 claims out of them, then the health claim settlement ratio of that health insurance company will be 94% for that particular year. 

There has always been a doubt in customers’ mind about whether the private company will keep its side of the bargain i.e. it will settle the claim or not. A customer spends the premium annually, which will cover his medical expenses but there’s always a concern in his mind about the claim settlement. 

Disclaimer: *Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by an insurer. 

The Incurred Claim Ratio mentioned in the table refers to the net claims paid by the Insurance provider as against the net premiums earned during the financial year. Incurred Claim Ratio (ICR) is basically the overall value of every claim a company has paid divided by the total sum of premium collected during the same period.

There are three vital health insurance claim ratios that one must understand:

• Claim settlement ratio
• Claim repudiation ratio
• Claim pending ratio

The Claim Settlement ratio tells us about the claim solving ability of the insurer. If claims are intimated and the insurer solves those, the claim settlement ratio would be good. A higher claim settlement ratio implies that the majority of claims are getting solved. Example- An insurer has a 60% claim settlement ratio which means that the insurer settles 60 out of 100 claims.

Health Insurance Settlement Ratio has been Calculated as = (Total Claims Settled)/ (Total Reported Claims + Outstanding Claims at Start of Year – Outstanding Claims at End of Year)

This is thus the proportion of claims (by number) accepted and paid by the insurance company during the year. The complementary number (i.e. 1-Settlement Ratio) gives the total proportion of cases that were unfavorably closed either as repudiation or as a closure.

Claims Repudiation Ratio= (Claims rejected/total claims) %

The claim repudiation ratio tells us about the percentage of the claims rejected by the insurer.

Example- Claim repudiation of 20% means 20 cases out of 100 are rejected.

The reasons for rejection could be false claims, untimely intimation, coverage not covered under the policy, etc.

Claims Pending Ratio= (Claims outstanding/total claims) %

Claims pending ratio tells us about the outstanding claims that have not been settled either way- neither accepted nor rejected.

Example- Claims pending ratio of 40% would mean 40 claims out of 100 are yet to be solved.

Health insurance claims could remain outstanding as a result of unfurnished information like doctors certificate. The insurer takes time to validate the expenses incurred during hospitalization.

*All savings are provided by the insurer as per the IRDAI approved insurance plan. Standard T&C apply.

How does Claim Settlement Ratio Data help me?

Health claims ratio data helps you understand the history of an insurance company’s claim settlement records. It should also be noted that new insurers typically would have a lower settlement ratio. That is because claims filed so early could probably mean a fake ratio. 

Yet claims data does enlighten us in analyzing companies that have been operating for the same period. Even though genuine claims are rarely rejected, knowing about claims does help you arrive at the final decision. If you think that two insurer products have more or less the same benefits, knowing that one insurer has 90% claim settlement could clinch the deal.

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Policybazaar’s View:

Health insurance claims are mostly accepted. That’s because the Insurer’s service of network hospitals where the cashless facility is available. In the case of non-network hospitals also, as long as treatment is within coverage limits and stipulated requirements have been fulfilled, claims will be accepted. It must be understood that no insurer rejects genuine claim requests.

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