Assessing Health Insurance Claim Trends in India

The average size of health insurance claims in India, as revealed by a research report by SecureNow, an insurance broker, stands at ₹42,000, with 15% of these claims exceeding ₹1 lakh. This analysis, based on 3,846 health claims filed through the reimbursement process, provides valuable insights into various aspects of health insurance in India, covering diverse geographical locations, insurers, family members, and both external and internal Third-Party Administrators (TPAs).

Evaluating Coverage Adequacy

The report underscores the importance for policyholders and insurance providers to consider potential high-cost scenarios, particularly hospitalizations exceeding five days and costing over ₹5 lakhs, when designing coverage options. Kapil Mehta, co-founder of SecureNow, emphasizes the significance of hospitalization duration as a critical factor in health insurance claims. Despite an average hospitalization period of two days, more than 21% of hospitalizations extend beyond three days, indicating the need for comprehensive coverage options.

Key Contributors to Claims

Day care procedures constitute 29% of all claims, necessitating coverage inclusion for such procedures in health insurance policies. While a hospitalization period of 24 hours is typically required for coverage, common day care procedures are often covered under most policies. Maternity claims comprise a significant portion, accounting for 20% of total claims, alongside contributions from fever (5%), eye surgeries (5%), and accidents (3%). Despite cancer claims representing only approximately one percent of total claims, their per-case cost is notably high, contrasting with accidents, which, despite their common occurrence, have an average cost of ₹33,000, lower than the overall average cost of claims.

Ensuring Smooth Claims Process

Submitting accurate and complete documents is paramount when filing health insurance claims. Essential documents include medical bills, prescriptions, diagnostic reports, discharge summaries, claim forms, policy documents, and any other requested supporting documents. These documents serve as necessary evidence for the claim and facilitate a smoother and faster claim settlement process. The report indicates an efficient claim process, with over 82% of required documents being submitted at the time of claim intimation and deficiencies in documents present in only 24% of cases. Such meticulous document submission enhances the overall efficiency and effectiveness of the claims process, benefiting both insurers and policyholders alike.