Claim Settlement Ratio : Get Hassle Free Claim Settlement

What is Claim Settlement Ratio?

A health insurance claim settlement occurs when a policyholder requests medical services from his or her insurer. By using this insurance, the policyholder can receive a cashless treatment or be reimbursed for the health services he or she has already received. Policyholders can ask their health insurance provider to offer cashless services or submit a claim settlement form for reimbursement. Choosing a company based on its health insurance claim settlement ratio is one of the most important factors because it tells you about the company's ability to settle claims. The whole point of purchasing insurance is lost if the company cannot settle the claims. Several insurance companies guarantee the settlement of claims within a specified timeframe, provided they are not fraudulent. An insurance company's customers are more likely to trust it when these aspects are present. Therefore, the Claim Settlement Ratio (CSR) of an insurance company reflects its reliability, which helps policy buyers make informed decisions regarding health insurance purchases. Insurance companies pay out a percentage of what they receive as claims during a financial year, known as the Claim Settlement Ratio. When purchasing a health insurance policy, CSR is considered one of the most important factors. In an emergency, insurance claims are the main reason for purchasing a policy. A health insurance claim settlement ratio is an important factor to consider before buying health insurance.

Types of Health Insurance Claim Settlement

In order to settle a health insurance claim, policyholders can utilize two different methods.

1. Cashless Claim Settlement Process - A health insurance provider's network hospital can treat the policyholder cashlessly under this type of claim settlement process. Hospitalization and treatment should be sought at the network hospital affiliated with the insurer for policyholders. Health insurance cards can be presented at hospital desks so that cashless claims can be processed. As a result of this claim process, the people do not have to pay anything from their pockets, as the insurer covers the entire medical bill directly with the hospital without involving them.

2. Reimbursement Claim Settlement Process - If an individual wishes to seek hospitalization in a hospital of their choice, they can utilize this type of claim settlement process. Through this claim settlement process, policyholders are free to choose any hospital of their choice and clear their medical debts. Upon submitting the necessary documents to the insurer, they can get reimbursed for the medical bills in their bank accounts. Patients who are able to bear the initial costs of medication at the time of treatment can benefit from this claim settlement process.

What is TPA (Third Party Administrator)?

TPAs are licensed outsourcing companies licensed by IRDAI that are chosen by specific health insurers. In this way, policyholders are able to settle their claims on time and without any hassles. In addition to supporting the claim settlement process, it also helps individuals resolve their claim-related issues and grievances. Cashless claim benefits are provided to policyholders through health ID cards. In addition to helping policyholders with cashless claims, it also aids them in settling reimbursement claims.

What is An House Claim Settlement?

Health insurance companies set up an internal claim-settling department or Health Administration Team within their organization. It performs the same tasks as TPAs. Health insurance companies have a separate department that assists policyholders with settling their claims on time without causing any inconvenience. In addition to resolving the grievances of policyholders, it settles their health insurance claims without delay.

Claim Settlement TPA v/s IN - House Claim Settlement

Points to Distinguish	Explanation
Experience with fast claim settlements	The in-house claim-settling departments excel when it comes to settling claims faster since they have a closer relationship with the insurance companies. Because they are part of an insurance company, they are faster because they have direct contact with the insurer.
A flexible approach	As TPAs do not approve or reject claims, they are considered more flexible. For either planned or unplanned hospitalizations, they offer cashless claims. A pre-approval of the claim can be obtained at the TPA counter at the company's network hospital. In addition to offering a direct connection, they assist policyholders in settling their claims.
A wide range of hospitals are part of the network	In comparison with the in-house claim settlement department, TPAs have a wider range of connections with the linked hospitals. A health ID is also issued to policyholders so that they can receive cashless benefits in case of an emergency medical situation.
Queries regarding the settlement of claims	In-house claim settlement departments resolve claim settlement-related discrepancies, while TPAs do not provide such benefits.

What is Incurred Claim Ratio?

An insurer's ICR is the ratio of total claims settled to total premiums received over a given period. Consider the following example to better understand this definition: The ICR of Company A is 75%. This means that the company pays Rs 75 as a claim settlement for every premium of Rs 100 collected. Profit is taken from the leftover Rs 25. The purpose of this metric is to tell us how likely the company is to pay a claim. In a company with an ICR of over 100%, more claims are settled than premiums are collected. Therefore, the company will experience financial difficulties in the long run if it continues to incur losses. If the company wants to earn a profit from this policy, it can either increase premium payments or make fundamental changes to it. Borderline claims are generally rejected by such companies. The best claim settlement ratio is between 50% and 100%, which indicates that the company is making a good profit and has introduced a good product. As a result of this ratio, it is also evident that the company has clearly understood the process of filing health insurance claims. Due to this, even customers are aware of when they should make claims and when they should not. An ICR below 50% indicates that the insurance company makes extremely high profits. It indicates either that premiums are being raised or that claims are being rejected. Customers do not benefit from either of these options.

The Process of Claim Settlement

Reimbursement or Cashless Claim processes are offered by your insurance provider. If you're not familiar with how these processes work, how do you approach them?

1) Process for making cashless claims - As its name suggests, cashless allows you to avoid handling cash in bulk. What is your method of paying your bills? Providing your insurance details to the hospital is your responsibility as an insurance provider. Physical proof can be provided or an e-card can be issued as part of the purchase process for a medical insurance policy. These proofs are all that is needed for the hospital to accept your request to treat you and process your claim. In any case, your insurance plan must cover the illness for which you have been admitted. Hospitals are responsible for forwarding all hospital bills to your insurance provider after you are discharged. When the hospital receives these bills, the respective departments review them thoroughly to determine the nature of the expense and settle the payment so that all dues are met. As part of this process, the hospital and insurance provider exchange payment instructions. You don't have to worry about how to pay your medical bills as an insurance holder. How do you file a claim as an insured citizen? In such a situation, you can consider a couple of methods. It is a planned event if you know it in advance. Occasionally, doctors inform you before surgery that you will have to undergo one. In fact, it could be any treatment that requires preparation in advance. It's always a good idea to let your insurer know at least 4 days in advance if you're seeking treatment at the network hospital. Providers differ, however, in their timeframes. There is more to it than that. In order to file a cashless claim, you need to submit it either physically or electronically to your insurance provider. Despite its slow pace, the post is widely accepted in the country. Upon receiving the plan information from the insurance agency, they coordinate future processes with the hospital and the insured regarding the progress of the process. For the process to start, the insurance holder only needs to provide their health care during admission to the hospital. In an emergency, what should you do? It is not always the case that illnesses arrive after an individual has been informed about them. An important fraction of hospital admissions results from emergencies or casualties. When something unforeseen or unplanned occurs, what should one do? In this case, the insured's family can always contact the insurance provider's customer service department. It is possible for the customer care representative to locate the nearest cashless facility and recommend it. However, the hospital must now submit a cashless claim form to the insurance company after receiving notification of the claim. In response to the form, the healthcare department provides the hospital with information about the coverage of the health insurance policy. The insurance company pays all medical bills. Hospitals and insurers are informed of rejection reasons and the reasons for not processing the claim. After discharge, the insured must maintain track of the same and follow it through to settlement. It is important to pay attention to the terms and conditions of hospital bills as well. Once the rejection criteria are determined and the payment is processed to completion, it would be an additional burden that would bother you long after your illnesses have been cured. In order to ensure that your family and friends do not have to look around for financial help instead of taking care of you, you should always inform them of details, such as the Mediclaim policy number, the coverage, the customer care center number, and the likes, if you purchase an online health insurance plan.
2) Reimbursement of Claim - It's a little tricky for the insured since they have to claim it from the service provider after they've been discharged. Basically, they pay their bills first and then apply for reimbursement later. Hospitals that are not network hospitals do not have to treat you in such cases. Don't forget to keep the bills of payment safe when you go to a hospital that can treat your ailments. The cashless claim process, however, is null and void in this case. Each original bill from the treatment should be submitted to the insurance company. Your claim cannot be supported or accepted by your insurance company without the original bills. Before a bill is cleared, it is analyzed and verified. To ensure there are no false claims, third-party authorization vendors are often hired. An example of a false claim would be a fraudulent bill, a document that has been manipulated, etc. During any stage of verification, if the claim falters or is found to be incorrect, it is rejected. In order to avoid failures at any stage of authorization, it is recommended to preserve the bills in a legible state and keep them intact until they are cleared. The claim is processed easily without any hassles after it is verified and found legitimate, and the payment is made to the insured's registered bank account. The insured is notified via customer advising methods if the payment is rejected due to any condition. The claim-processing department may contact you by phone, email, or post. A person might question whether medical bills are sufficient documentation to get reimbursed by their healthcare provider. To make the process successful, you must have certain documentation in place. Your claim progress can be halted if a document is missing. Because you do not know what document it is, you do not want to run from pillar to post! Therefore, we have consolidated a list that you can refer to during the claim process. You can always ask the agent who sold you your mediclaim policy to provide you with a manual that explains everything.

Documents That Are Also Mandatory Include:

A claim form that has been duly filled out and signed. A copy of this document can be downloaded online or obtained from the insurance company.
Report of investigation
Original receipts, bills, memos, etc. Your loss will be accounted for if a bill is missing.
Several documents need to be signed by your doctor, including a medical certificate and your case file. Basically, it is an attested copy of your hospital record of illness.
An external pharmacy has provided a cash memo for the purchase of medicines.
Documents related to clearance, including discharge card, summary report, and clearance certificate.
In cases of medical emergencies, such as accidents or casualties, an FIR should be filed. A Medico-Legal Certificate should be provided if the FIR is not available.

In the end, the claim is deemed completed once all documents have been verified and processed. When you purchase health insurance, your insurer declares an account where you will credit the entire claim amount. Verification of your documents and claims is usually handled by third-party administrators. Due to higher incentives to limit claims, they take strict steps to reject or cancel any claim they receive. As instructed by the insurance providers, this is what should be done.

Things To Keep In Mind At The Time of Health Insurance Claim

1. Medical insurance validity - Ensure that you have a valid medical insurance plan before filing a health insurance claim. Your health insurance plan will not be honored by the insurance company if it has expired and you have not renewed it. Keeping track of your medical insurance plan's validity and ensuring its timely renewal is therefore crucial. Make a note of the tenure and expiration of your health insurance plan, as well as set a reminder for its renewal, if you have purchased it as an individual or as a family. As a result, you will not be left stranded without health insurance benefits when they become necessary.
2. Your health insurance plan's inclusions and exclusions - You should review your health insurance plan's inclusions and exclusions carefully. In order to fully understand the extent of your coverage, you must read the policy document in its entirety and note the aforementioned details. Additionally, this exercise helps you determine which health insurance plan is best suited for you and/or your family. It is important to remember that if you file a health insurance claim for an illness or condition that is not covered by your medical insurance plan, the claim will be void from the beginning. Consequently, you should ensure that you understand your health insurance plan's inclusions and exclusions.
3. Specific diseases and medical conditions covered and the waiting period - There are some illnesses that are covered by a basic health insurance plan, but there are others that are not. Some medical insurance plans do not cover pre-existing conditions and critical illnesses. If these illnesses are covered, there may be a waiting period before the coverage becomes active. A health insurance plan that covers pre-existing illnesses is therefore recommended if you have one. Additionally, you can purchase a medical insurance add-on that covers critical illnesses. You can ensure adequate coverage for your health insurance needs by following this simple process when filing a health insurance claim.
4. Your insurance provider's health insurance claim process - You must follow your insurer's claim process for health insurance when purchasing a health insurance policy and consider the following points:

Claim filing timelines for network hospitals and non-network hospitals.
A cashless claim and a reimbursement claim require various documents.

5. Your insurer's cashless hospital network - The extensive hospital network of medical insurance providers is one of the most valued features of contemporary Indian health insurance. The network offers cashless medical insurance and cashless claims, so you can have a relatively worry-free claims experience.
6. Filing a claim requires certain documents - You must keep certain documents handy to ensure that your claim is sufficiently supported and substantiated, whether you are filing a cashless claim or a reimbursement claim.
For filing a medical insurance claim, you will need the following documents:

A copy of your health insurance card.
A copy of your health insurance policy.
Proof of your photo identification and address.
For accidental claims, a copy of the First Information Report was filed with the local police.

Additional documents will be required if you received medical treatment at a non-network hospital, including:

A medical certificate signed by a licensed physician.
Original hospital and pharmacy bills.
Reports of pathological tests applicable.
The letter of discharge from the hospital.
Reimbursement details via NEFT.

Document Required For Claim Settlement

If you provide the insurer with the proper documents, the claim settlement process becomes easier and more hassle-free. Your health insurance claim will be approved after those documents are verified. While claiming your health insurance policy, you may need the following documents.

Claim Form filled out - The insurance company's website or the hospital's desk have a claim form that needs to be duly signed and carefully filled out. It is important that the details in the form are accurate and verified. The purpose of this form is to initiate the claim settlement process with your insurer. In the case of planned treatment, it can be filled out before hospitalization, otherwise, it can be submitted as soon as possible after hospitalization.
Certificate of Medical Fitness - Your other claim settlement documents should be accompanied by a proper medical certificate issued by the hospital and signed by the doctor.
Reports of diagnosis - For you to receive the full benefits of your health insurance policy, all your medical reports, such as diagnosis reports, blood test results, etc., must be submitted with the policy-related documents. These reports are required as valid proof of your hospitalization and treatment if you are claiming reimbursement.
Proof of valid ID - Please attach the necessary identity proofs such as an Aadhar card, driving license, PAN card, ration card, etc., as mentioned in the policy documents. These documents must be attached.
Documents related to discharge - Your discharge card or other documents obtained from the hospital authorities must be submitted with the claim documents.
Bills for medical care - Any prescriptions, receipts, or other medical bills covering your treatment expenses must be collected and attached to the claim.
A copy of the police report - In case of an accident, the FIR report must be attached to the claim documents. Your health insurance policy must be claimed if the bodily injuries were caused by an accident.

Reason For Rejection of Health Insurance Claim

A health insurance policy's fine print is often ignored by most of us. In this case, the consequences are not taken seriously and the situation is not taken seriously. Health insurance claims can be rejected if you are lax about them. If you don't understand the gravity of the situation, this might seem less serious. The experience would be quite exhaustive and punitive for those whose claims were denied. Therefore, it is important to know why a claim may be rejected. Additionally, it is crucial to understand preventative measures. "Prevention is better than cure", according to a popular saying. Additionally, avoiding rejection is better than taking remedial measures later in the insurance sector. As long as you are able to convince the insurer that your claim is genuine, an insurer will entertain your claim post-rejection. In order to take corrective measures, you must first determine why it was rejected. Your claim may be denied for a variety of reasons. Getting admitted to a non-network hospital, ignoring exclusions, etc. can cause these problems. Therefore, let's discuss the 4 reasons why your claim may be rejected.

1. Exceeding the sum insured - Do you know what Sum Insured is? In a health insurance policy or a personal accident policy, there is an insured sum involved - whether it is a family floater or a personal health insurance policy. You or your family can access the sum insured annually based on the type of plan you choose. The following cashless claims will be rejected if you have used your entire sum for the year. Nonetheless, if part of your sum assured is still intact, the insurer might reimburse you later.
2. Disregarding exclusions - Most health insurance plans do not cover several diseases. These are specifically listed as 'not covered' in the policies. There are a number of diseases that are excluded from insurance coverage and therefore cannot be claimed for. Nevertheless, if certain policies or plans cover such diseases, there will be a waiting period. It is obvious that you will be rejected if you file a cashless claim for one of these diseases/medical conditions that are excluded.
3. Facts are suppressed or misrepresented - Claims are rejected for a variety of reasons, such as non-disclosures, partial disclosures, and incorrect disclosures of important details, such as age, occupation, income, insurance plans, and major ailments. A claim can be rejected if there is a discrepancy between the declaration and the reality during the time of filing the claim. Coverage is based on the information provided by the proposer on the proposal form. When filling out forms, be prompt and specific.
4. Overstaying the time limit - There is a specific period of time within which you must apply for reimbursement under a health insurance policy. A 24-hour window is given for emergency admissions, but depending on your policy and the treatment you are receiving, this can vary. In the event that you don't submit your claim within the specified time frame, your claim may be rejected.

How To Avoid Claim Rejections?

To name a few, health insurance covers medical expenses, hospitalization costs, consultation costs, and ambulance fees for policyholders. Insureds benefit from mental peace and safety. In some cases, a health claim is rejected, causing confusion and bitterness. In order to avoid mistakes that could result in the rejection of a claim, one must know the basic reasons why the claim might be rejected.

Policy tenure - A health insurance policy is typically a time-bound contract that must be renewed annually. In some cases, policyholders do not realize their contract has expired until their claims are rejected, which comes as a shock to them. Please note that the insurance company cannot pay a claim if the policy has expired. It is crucial to keep track of the policy renewals to avoid such unpleasant experiences. There is no need to panic, most insurers offer a grace period of 15 days during which you can renew your policy without losing the benefits. Insurers, however, will not accept any claims during the break-in period.
Non-disclosure of pre-existing diseases or other relevant information. The insured should disclose any pre-existing conditions or ailments, such as blood pressure, cardiovascular conditions, hypertension, etc. It is also important to disclose if one has ever undergone any major surgery in the past. A new medical condition or ailment acquired during the year should also be disclosed at the time of insurance renewal. To avoid hassles when claiming a health insurance policy, it is essential to share details related to health with the insurer. A pre-existing condition may have permanent exclusions or may materially impact the decision to accept a proposal, so it is important to disclose these details.
Period of waiting - In health insurance, the waiting period refers to the predetermined period during which the claim cannot be filed for the mentioned ailment or condition. Depending on the insurer and the illness, the waiting period begins at the start of the policy. Before the insurer is liable for the mentioned illness, the policyholder must serve the waiting period. In order to understand the duration of waiting periods against the specified ailments, the policyholder should carefully read the waiting period clause. The claim will be rejected if it is made during the waiting period.
Policy coverage for illnesses - Policyholders will get rejected if their claim is raised against an ailment that is specifically listed as an exclusion in their insurance policy. To understand what is not covered by the policy, one must go through the list of exclusions.
Time limit to raise claim - The insurance policy stipulates a timeline within which the policyholder must raise the claim, typically 60-90 days from the date of discharge. If the timeline is not followed, the claim may be rejected. The claim should be filed as soon as possible after the discharge. If the insurer has a genuine reason for the delay in submitting the claim, the insurer may admit the claim.
Documentation is inadequate or incorrect - It is not uncommon for reimbursement claims to be rejected because of missing or incorrect documentation. In order to avoid any issues, the policyholder must submit all original documents, test reports, doctor consultation letters, and other requisite documents along with the duly completed claim form. A preferred network hospital is also highly recommended to ensure a smooth claim settlement since these hospitals offer cashless services, better rates, waiver of certain charges, and other non-insurance benefits. Hospitals impaneled with most insurers are spread across the country, which makes settling claims hassle-free. So long as the claim form is filled out completely and the supporting documents are submitted, a policyholder should not have any major issues with claim settlement.

Claim Settlement Ratio of Health Insurance Companies

Points to distinguish	Explanation
Experience with fast claim settlements	The in-house claim-settling departments excel when it comes to settling claims faster since they have a closer relationship with the insurance companies. Because they are part of an insurance company, they are faster because they have direct contact with the insurer.
A flexible approach	As TPAs do not approve or reject claims, they are considered more flexible. For either planned or unplanned hospitalizations, they offer cashless claims. A pre-approval of the claim can be obtained at the TPA counter at the company's network hospital. In addition to offering a direct connection, they assist policyholders in settling their claims.
A wide range of hospitals are part of the network	In comparison with the in-house claim settlement department, TPAs have a wider range of connections with the linked hospitals. A health ID is also issued to policyholders so that they can receive cashless benefits in case of an emergency medical situation.
Queries regarding the settlement of claims	In-house claim settlement departments resolve claim settlement-related discrepancies, while TPAs do not provide such benefits.

FAQ

What is the maximum number of health insurance claims a policyholder can request each year?

During a policy year, you can file an unlimited number of claims. Claims can be made until the sum insured of the policy has been exhausted.

What is the average time it takes for an insurer to settle a health insurance claim?

From the moment the insurance provider receives the last relevant document, the claim request is generally settled within seven working days.

In health insurance, what is a claim settlement ratio?

Health insurance claims settlement ratios are calculated by comparing the number of claims settled to the total number of claims filed over the course of a year.

Knowing the claim settlement ratio has what benefits?

Insurance providers are ranked according to their claim settlement ratio, or Claims Paid Ratio, which helps determine their reliability.

Can I submit a claim for health insurance within a certain period of time?

As a general rule, this should be completed within 90 days of discharge from the hospital.

In-house claim settlements: what are they?

As a separate department within the health insurance company, this department helps policyholders settle their claims on time without any hassle

What is the best way for policyholders to inform their insurer about hospitalizations?

Hospitalization should be announced at least three to four days in advance. It is necessary to fill out and submit a pre-authorization form to the insurance company.