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India's average health insurance claim is Rs 42,000; 15% exceeding Rs 1 lakh: Study

The study highlights the need for policyholders and insurance providers to consider potential high-cost scenarios, such as hospitalizations exceeding five days and costing over Rs 5 lakh.

• By Pooja Chaturvedi Sah
• New Delhi
• Jun 28, 2023

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Offering insights into the various aspects of health insurance in India, a study by Delhi-based insurance broker SecureNow has found that the average cost of health insurance claims in India is Rs 42,000, with 15% of these claims exceeding Rs 1 lakh.

Just 0.2% were for amounts greater than Rs 1 million, while 85% claims were for less than Rs 100,000, as per the study. 

The analysis is based on 3,846 health claims filed through the reimbursement process (as opposed to cashless). These claims were geographically diverse and covered different kinds of insurers, family members, and both external and internal TPAs.

Titled Reimbursement Health Insurance, this comprehensive report has covered areas including hospitalization duration, claim costs, settlement rates, and the efficiency of the claim settlement process in India.

This highlights the need for policyholders and insurance providers to consider potential high-cost scenarios, such as hospitalizations exceeding five days and costing over Rs 5 lakh, when designing coverage options. 

According to the study, typical hospitalization is for two days, but over 21% hospitalization extend beyond three days. Day-care procedures account for 29% of the claims. 

Maternity claims contribute to 20% of total claims. Fever (5%), eye surgeries (5%), and accidents (3%) also contributes to the overall claim volume. Although cancer accounts for approximately 1% of claims, the per case cost is relatively high. 

Additionally, less than 3% of claims are due to accidents, with a lower median cost of Rs 33,000. “This underscores the necessity for comprehensive coverage that accounts for longer hospital stays”, according to SecureNow’s co-founder Kapil Mehta. 

“At least 50% of claims have a settlement rate of 80% or higher of claims made,” said Mehta. 

The report revealed that nearly 51% of insurance claims were assessed by private insurers. More than 82% of required documents are submitted at the time of claim intimation. In 76% of cases, there are no deficiencies in the documents, as per the report.