Health Insurance Claim Settlement Ratio

What is a Claim Settlement Ratio in Health Insurance?

Claim Settlement Ratio or CSR in health insurance is the ratio of the total number of claims settled by an insurance company against the total number of claims filed in a financial year. It is a direct reflection of how trustworthy a health insurance company is. It indicates how likely an insurance company is to pay the claims received.

The formula to calculate health insurance Claim Settlement Ratio (CSR) is:

Claim Settlement Ratio = (Total Number of Claims Paid by the Health Insurance Company/ Total Number of Claims Received) X 100

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 claim settlement ratio of the health insurance company will be 94% for that year.

Every health insurance company in India has a claim settlement ratio. Usually, a claim settlement ratio above 85% is considered good in health insurance. A high claim settlement ratio indicates that the insurance company has a higher ability to pay for claims.

Latest Claim Settlement Ratio of Health Insurance Companies (2021-2022)

Check out the latest claim settlement ratio and incurred claim ratio of health insurance companies in India:

*CSR Source: IRDAI Annual Report 2021-22
*ICR Source: IRDAI Annual Report 2022-23
The above table was last updated on 17th October 2024.

*Disclaimer: The list mentioned is according to the alphabetical order of the insurance companies. Policybazaar does not endorse, rate or recommend any particular insurer or insurance product offered by any insurer. This list of plans listed here comprise of insurance products offered by all the insurance partners of Policybazaar. For complete list of insurers in India refer to the Insurance Regulatory and Development Authority of India website www.irdai.gov.in.

Note: The Incurred Claim Ratio (ICR) in health insurance refers to the ratio of the total claim amount paid by a health insurance company against the total premiums collected in a financial year.

People also read: Claim Settlement Ratio vs Incurred Claim Ratio – Know the Difference

Importance of Claim Settlement Ratio in Health Insurance

Here are some of the reasons why checking the claim settlement ratio of the insurance company is important before buying health insurance:

1. Indicates Insurance Company’s Claims-Paying Ability

   The claim settlement ratio indicates a health insurance company’s ability to pay claims. If the insurer settles the claims received on time, the CSR would be good. A higher claim settlement ratio implies that the insurer has paid most of the claims received. For example, if an insurer has a claim settlement ratio of 80%, it means that the insurance company has settled 80 out of every 100 claims.

2. Measures Reliability & Consistency of the Insurance Company

   The CSR can help you assess if a health insurance company will be reliable at the time of claim settlement. An insurer with a high CSR will be more likely to settle your claim than a lower CSR. Thus, CSR can be used to decide which health insurance company is more dependable.

3. Checks Consistency of the Insurance Company

   The CSR can help you check the claim settlement trends of a health insurance company over the years. This can help you check how consistently an insurer pays the claims filed by policyholders.

4. Helps to Compare Health Insurance Plans

   Claim settlement ratio is an excellent way of comparing health insurance plans before buying. You can compare the claim settlement ratios of different health insurance companies before finalizing a medical insurance policy. For instance, if two health plans have similar coverage and premiums, then you can go for the insurer that has a better claim settlement ratio.

How to File a Claim with a Health Insurance Company?

There are two ways to file a claim with a health insurance company & cashless claims and reimbursement claims. Take a look at the process to file both types of health insurance claims below:

Cashless Claims:

Cashless claims can be filed when the insured obtains treatment at a network hospital of the health insurance company. To file a cashless claim, you need to:

1. Intimate the insurance company about your hospitalization.
2. Fill out the pre-authorization form and submit it to the insurer/TPA.
3. The insurer will authorize your cashless treatment after verifying the documents.
4. Obtain the treatment and sign all the documents during discharge.
5. The health insurer will pay the bill amount directly to the network hospital.

Reimbursement Claims:

Reimbursement claims can be raised when the insured obtains treatment at a non-network hospital of the insurer or when the cashless claim has been rejected. To file a reimbursement claim, you need to:

1. Intimate the insurance company as soon as you get hospitalized.
2. Obtain treatment and pay all the bills at the time of getting discharged from the hospital.
3. Submit all the required claim documents to your insurer.
4. The insurer will pay you the claim amount after verifying all the documents.