Best Claim Settlement Health Insurance Company: CSR Calculation & Claim Process

Claim settlement ratio or CSR is the percentage of claims an insurance company settles in a given year out of the total claims received. Typically, the claim settlement ratio serves as a reliable indicator of credibility. In fact, the industry believes that the higher the CSR, the more reliable the insurance provider is. This is why most individuals make it a point to check the CSR of their choice of insurance providers. Let’s take a look at some of the best claim settlement health insurance companies in India.

Best Claim Settlement Ratio in Health Insurance List 

Take a look at the table below to gain an insight into the best claim settlement ratio in the health insurance list:

Insurer	Policies	Amount in Crores	Amount in Crores	Percentage of Total Claims	Amount in Crores
Navi Health Insurance				97%*
LIC	75,8916	Rs. 13,694.34	Rs. 12,797.85	93.45%	Rs.205.02
Bajaj Allianz	12,127	332.15	310.71	93.55%	20.78
Aviva	810	83.33	80.78	96.94%	0.97
Max Life	15463	595.43	562.54	94.48%	32.88
Tata AIA	2982	231.96	222.47	95.91%	9.49
Reliance Nippon	8017	167.03	157.03	94.01%	9.43
Aegon	351	69	64.6	93.63%	4.4
Star Union	1248	53.29	50.47	94.71%	2.1
Bharti Axa	1320	64.29	61.56	95.75%	1.58

Note that this table is for illustrative purposes only.

*Terms and Conditions Apply

Benefits of Claim Settlement Ratio

The claim settlement ratio of insurance providers comes in handy in more than one way. These are among the top benefits:

It indicates the insurer’s reliability

The claim settlement ratio serves as an indicator of the insurer’s credibility. In other words, it indicates that the insurance provider is capable of paying the sum assured to the policyholder or his/her nominee. Typically, an insurance provider with a consistently high CSR is more likely to meet their commitment, and pay a sum assured as and when a claim is raised. 

CSR ensures financial security

Insurance providers with the most claim settlement track records are most likely to follow a transparent claim process. In such an arrangement, it is expected that the claim process will be hassle-free. As a result, the policyholder or his/her family will be able to access the sum assured without going through any rigorous formalities. 

Importance of Claim Settlement Ratio in Health Insurance Policies

Here are the details:

• Its details provide the important insights into the insurer’s consistency for claim settlements

• Claim settlement ratios are an important metric to compare health insurance providers

• Details about claim settlement ratios provide crucial information about a company’s ability to pay claims

• It indicates the reliability of a company

• It can be used to measure competitors’ performance

How is Claim Settlement Ratio or CSR Calculated?

Claim Settlement Ratio or CSR is calculated using this formula –

Claim Settlement Ratio = (Total claims settled in a year/ Total claims received in a year) X 100

For instance, an insurance company, say XYZ, settled 9,000 claims out of 10,000 claims for 2020-2021. Based on the formula XYZ’s CSR will be,

= (9,000/10,000) x 100

= 90% 

Also Read: Understanding Health Insurance Claim Settlement Ratio In India

Significance of a High Claim Settlement Ratio in Health Insurance Policies

A high claim settlement ratio is significant because it indicates that the claim settling ability of the insurance provider is high. 

For example, a Claim settlement ratio of 96% indicates that the insurer has settled 96 claims out of 100. 

Different Types of Ratios in an Insurance Policy

An investor needs to be aware of the following ratios before investing in a health insurance policy:

• Solvency ratio
  It reflects a company’s financial situation based on defined solvency norms

• Persistency ratio
  It reflects how persistent customers have been in renewing their policies. It acts as an indicator of customers’ trust in the insurer’s products and services

• Combined ratio
  This ratio reflects the entire outflow of a general insurance company with respect to paid commissions, operating expenses and incurred claims and losses on the net earned premium. 

• Incurred claims ratio
  This metric shows the general insurer’s ability to pay claims

• Commission expense ratio
  This ratio shows the outflow towards commissions from the written premium during a particular period of time

• Claim settlement ratio
  It shows the number of claims settled by the insurer against the number of claims received

Documents Required for Making a Health Insurance Claim

Given below are the documents required to make a health insurance claim:

• Filled Claim Form
  The policy-holder has to fill up and submit the claim form, which he/she can download either from the official website or collect from the nearest office of the insurer. 

• ID Proof
  One must submit valid ID proofs like Aadhaar, PAN card, driving license, ration card etc. 

• Diagnosis reports
  The policy-holder must submit every necessary diagnosis report including blood test reports 

• Medical certificate
  One needs to submit a medical certificate signed by the doctor and authorized by the hospital

• Medical bills
  One must attach prescriptions, medical bills and receipts of other expenses with the claim application

• Discharge reports
  One has to submit documents related to discharge as well

• FIR copy if applicable
  If there was an accident followed by a police case, one must attach the FIR copy

Factors Affecting Claim Settlement Ratio

Given below are the factors affecting the claim settlement ratio:

• Total number of claims paid during the time period
  This is an important factor as it reflects the financial ability of the company to pay the amount when the insured person needs it the most. However, one must keep in mind the terms and conditions to avoid rejection of claims. 

• Total number of claims received by an insurance company
  The policy-holder needs to take into account the total number of claims received by the insurer as it indicates the reliability of the company. If many people raise claims, it means that many people are relying on a particular insurance provider to fulfil their needs. 

Things to Remember about Claim Settlement Ratio

The claim settlement ratio should never be the sole factor when it comes to selecting a particular health insurance provider.

Individuals should also keep these points in mind when glancing through the best claim settlement ratio in the health insurance list to select an insurer: 

• CSR indicates a percentage for all insurance policy plans. In other words, the best claim settlement ratio in health insurance does not necessarily indicate the claim settlement specification of any particular plan. Instead, it shows a collective track of all plans, including ULIPS, term plans, and endowment plans.
• Since the CSR of an insurance company is likely to change each year, it does not serve as a robust indicator of its offerings. 
• To decide the merit of the insurance provided by any insurance company, individuals must weigh the features, benefits and claim process accompanying its policies.

Health Insurance Claim Settlement Process

Insurance providers offer cashless claims and reimbursement claims.

Steps to make cashless medical insurance claims:

Step 1: Visit a network hospital for medical treatment

Step 2: Inform the insurance provider of your hospitalization as soon as you can. Remember that the terms and conditions of the policy mention the time period of claims

Step 3:  Submit your cashless card/member ID/policy number at the hospital. Fill up the pre-authorization form 

Step 4: The hospital forwards the pre-authorization form to the insurance provider. At the insurance company, the claim is minutely examined by the relevant team and conveys the hospital and the policyholder for claim approval 

Step 5: If approved, the insurance provider pays the medical bills. If rejected, the policy-holder has to make the payments 

Steps to make health insurance reimbursement claims:

Step 1: Inform the insurance provider as soon as possible

Step 2: Download the reimbursement form from the website of the insurance provider or collect it from their office

Step 3: Fill up the claim form, attach all the required documents and submit it to the insurance company

Step 4: The insurer would examine the reimbursement claim minutely

Step 5: If approved, the policy-holder would receive the amount within 30 days 

Please note that the above procedures mentioned are general procedures. Cashless claim and reimbursement claim processes may vary from one insurer to another. 

Also Read: Understanding Health Insurance Claim Settlement Ratio In India

Top Reasons for Health Insurance Claim Rejection

Given below are the top reasons for claim rejection for health insurance policies:

• The insurer will reject the claim if the health insurance policy has expired

• Rejection will take place, if the treatment, for which the policy-holder is making a claim, is not listed in the insurance policy

• Insurer will reject the claim if the policy-holder makes a claim for a pre-existing illness without completing the waiting period

• Rejection will take place if policy-holder make false claims

• Insurer will reject the claim if the policy-holder makes a claim for a treatment which is specifically excluded

5 Ways to Avoid Health Insurance Claim Rejection 

Given below are the ways to avoid health insurance claim rejection:

• Policy-holder should fill up the claim form on their own
  Instead of relying on the agent, policy-holders should fill up the claim forms on their own to avoid errors.

• The information provided should be accurate
  Policy-holders should disclose the information regarding their age, income and pre-existing illnesses accurately.

• Policy-holder must avail treatment from a network hospital only
  If a policy-holder avails treatment from a non-network hospital, the insurer might reject the claim. So, it is important for the insured to minutely scrutinize the list of the network hospitals to avoid claim rejections. 

• Claims should be made only for the relevant medical treatment
  There have been instances when patients had to undergo medical procedures that weren’t really necessary due to hospitals asking them to do so. However, if these procedures are not aligned with the medical treatment or health condition of the insured, the insurance provider will reject the claim. 

• Policy-holder should study the terms and conditions minutely 
  The insured person needs to minutely study the terms and conditions. This helps them be aware of the exclusions and inclusions of the insurance policy which in turn would help them make the right claim. 

Limitations of Claim Settlement Ratio as a Selection Criteria for Health Insurance Policies

The disadvantages of the claim settlement ratio are as follows:

• Claim settlement ratios reveal numbers only. It doesn’t provide any information about the amount provided against each of the claims. 

• Claim settlement ratio doesn’t measure efficiency. For example, an insurance company might have a high claim settlement ratio but the claim procedure might be burdensome and lengthy. 

The policy-holder can study reviews of insurance policies before zeroing in on one. 

Tips to Choose the Right Insurance Policy

While looking for the best claim settlement insurance company, keep these pointers in mind to select a suitable policy plan: 

Tip 1: Identify the type of insurance policy you need

First, one should identify whether an individual insurance policy or a family floater policy plan is more suited in his/her case. Accordingly, one should proceed to find out whether he/she will be well off with a general insurance policy or a health insurance plan. 

Tip 2: Look for an extensive coverage

To make the most of an insurance policy, it is always best to choose a policy plan with extensive coverage. Individuals should always look for an insurance policy that extends a high sum insured/assured and offers multiple features that benefit them in case of a financial emergency. 

For example, in case of a medical emergency, having a health insurance policy that comes with a short waiting period and follows a quick claim settlement process will allow the policyholder to avail of the best quality treatment.

Tip 3: Compare quotes

Individuals can make sure that their insurance policy does not burn a hole in their pocket by comparing the premium and sum insured of the leading health insurance policies online. 

They can easily compare quotes online by simply entering relevant personal and policy requirement related details and selecting a plan that matches their investment intent and requirement perfectly. Also, with the help of an online insurance premium calculator, they can easily plan their finances and streamline financial obligations easily.

Tip 4: Find Out About Claim Process

An insurance policy that accompanies a quick claim settlement process is ideal when it comes to availing of such a plan. These policies allow the insured to avail of cashless treatment from the best network hospitals or get promptly reimbursed for their medical bills. 

For example, Navi Health Insurance helps insured individuals to get their claims settled in 20 minutes and receive cashless treatment from more than 10,000 network hospitals. This allows the policyholder to avail the best of medical assistance at the earliest and without straining available savings.

Tip 5: Check network hospital coverage

It is important to check the TPAs and network hospitals under the third-party administrators to ensure a hassle-free claim process when availing of a health insurance policy. Also, checking the network hospital coverage in advance will help individuals analyse whether they can get quality treatment from leading hospitals located nearby in case of emergency.

Tip 6: Check exclusions 

Individuals must make it a point to check out the exclusions of an insurance policy before availing it. Typically, leading insurance providers follow a standardised list of exclusions set by the IRADI and third-party regulators. 

Regardless, many insurance providers go above and beyond those exclusions and include additional ones to the existing list. Not having a proper idea about those exclusions can jeopardise insureds’ chances of settling a claim. 

Subsequently, they should check details about exclusions related to pre-existing conditions and other related limitations on coverage to gain a better idea about the policy and its extent of coverage. 

Reasons to Buy Family Health Insurance Plans from Navi

The following features and offerings make Navi a viable insurance provider in more than one way:

• Navi follows a simple and hassle-free claim process that does not involve any agent.
• Policyholders can avail themselves of health insurance online in 90 seconds* via the Navi app.
• Navi has a network of  10,000+ network hospitals in the country.
• Policyholders can settle cashless claims in 20 minutes*.
• We offer extensive coverage at a nominal insurance premium.
• The digital process ensures a hassle-free experience of availing of an insurance policy in no time.

Download the Navi app today and sign up for a comprehensive health insurance plan to protect yourself and your family from life’s uncertainties. 

Final Word

Selecting an insurance provider by looking at just the best claim settlement list may not be a smart move. However, supplementing the same by scrutinising the features, terms of claims, offerings, and limitations could prove an effective way of selecting an insurance provider. 

FAQs on Companies with Best Claim Settlement Ratio

Before you go…

How about an affordable health insurance policy 👨‍⚕️ starting at a monthly premium of just ₹235? Install the Navi app now and get your policy in under 2 minutes.

Disclaimer: This article has been prepared on the basis of internal data, publicly available information and other sources believed to be reliable. The information contained in this article is for general purposes only and not a complete disclosure of every material fact. It should not be construed as investment advice to any party. The article does not warrant the completeness or accuracy of the information, and disclaims all liabilities, losses and damages arising out of the use of this information. Readers shall be fully liable/responsible for any decision taken on the basis of this article.