Average health insurance claim in India is Rs 42,000, with 15% exceeding Rs 1 lakh: Study

The average cost of health insurance claims in India is Rs 42,000, with 15% of these claims exceeding Rs 1 lakh, revealed a study by tech-enabled insurance broker SecureNow called Reimbursement Health Insurance Claims.

The comprehensive report has significant findings on hospitalisation duration, claim costs, settlement rates, and the efficiency of the claim settlement process in India.

SecureNow analysed 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.

According to the study, while the average cost of health insurance claims was Rs 42,000, 15% of claims exceeded Rs 1 lakh, indicating substantial expenses for a portion of claimants. This highlights the need for policyholders and insurance providers to consider potential high-cost scenarios, such as hospitalisations exceeding five days and costing over Rs 5 lakh, when designing coverage options.

Furthermore, less than 3% of claims are due to accidents, with a lower median cost of Rs 33,000. The report emphasises that the duration of hospitalisation is a critical aspect of health insurance claims, according to SecureNow’s co-founder Kapil Mehta.

The comprehensive study reveals that the typical hospitalisation period is two days, but more than 21% of hospitalisations extend beyond three days, said Mehta. “This underscores the necessity for comprehensive coverage that accounts for longer hospital stays,” he added.

Additionally, day-care procedures constitute 29% of all claims, highlighting the importance of including coverage for these procedures in health insurance policies, SecureNow said.

Mehta added that the research report also indicates relatively high claim settlement rates, with over 50% of claims having a settlement rate of 80% or higher. Among segments, maternity claims contribute significantly, comprising 20% of total claims.

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

Furthermore, the research report highlights the efficiency of the claim settlement process, stating that 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.