Health Insurance Claim - India

94% of health insurance claims are typically approved by insurance companies, underscoring a robust foundation within the industry, according to a recent report. Notably, this figure climbs to 97% for claims initiated through online channels, demonstrating the efficiency and potential transparency facilitated by digital platforms in the claims process.

Furthermore, the integration of online platforms results in a significant decrease in Rejection rates, dropping from an average of 6% to just 2.5%.

Claim Payouts and Consumer Satisfaction - While approval rates are encouraging, the report identifies an area for improvement in claim payout amounts, which currently stand at 87%. Ensuring a 100% payout percentage remains an aspiration, particularly by enhancing awareness about add-ons like consumables cover.

Customer Satisfaction: A Key Metric - Customer satisfaction emerges as a pivotal metric in evaluating the health insurance landscape. The report highlights that 86% of customers reported satisfaction with their claim experiences. This positive feedback reflects the industry's ongoing efforts to meet and exceed customer expectations, bolstering overall trust in insurance providers.

Reasons for Claim Rejections - Despite high approval rates, a significant proportion of claim rejections (6%) stem from non-disclosure of pre-existing or uncovered diseases. This issue underscores the importance of transparent communication between insurers and policyholders at the time of purchase to prevent such pitfalls.

Role of Intermediaries in Claim Reversals - The involvement of intermediaries in the claims process significantly influences the outcomes. When customers resubmit rejected claims themselves, only 6% succeed in having their decisions reversed. However, this rate improves dramatically to 32% with the assistance of offline agents and jumps to 67% when utilizing online intermediaries.

Cashless vs. Reimbursement Claims - The report delves into the preferences and challenges associated with cashless and reimbursement claims. Notably, 70% of reimbursement claimants seek financial aid to cover upfront payments, indicating a reliance on out-of-pocket resources due to various factors such as the unavailability of cashless facilities or preferred healthcare providers not being in the insurer's network.

Despite an 86% satisfaction rate, there is room for improvement given the high stakes involved. Key strategies include enhancing cashless claim availability beyond metropolitan areas, improving efficiency in claims processing, and bolstering on-ground presence for psychological comfort, the report highlights.