A Complete Guide on Health Insurance Claim Settlement Ratio

When comparing health insurance plans, the health insurance claim settlement ratio is one of the most crucial factors to consider. A claim settlement ratio is important for assessing an insurer’s credibility, ensuring faster claim approval, and so on. Generally, a claim settlement ratio above 90% is considered good.

In addition, customers should check the insurer’s public disclosures for the most accurate and updated figures. Continue reading for a list of the top 10 health insurance providers in India with a high claim settlement ratio, and other relevant details.

What is the Health Insurance Claim Settlement Ratio?

The health insurance claim settlement ratio denotes the percentage reflecting the number of claims an insurance company can actually settle against the number of claims received within a stipulated time frame, typically any financial year.

For instance, if an insurance company settles 98 of the 100 received claims, the claim settlement ratio is 98%. This ratio is set by the Insurance Regulatory and Development Authority of India (IRDAI).

This health insurance claim settlement ratio provides detailed insights into the reliability and efficiency of an insurance company in terms of processing accurate claims without delay.

Why is the Claim Settlement Ratio Important in Health Insurance?

When it comes to choosing a reliable and convenient health insurance provider, the claim settlement ratio plays a crucial role. A high claim settlement ratio indicates higher chances of claim approval hassle-free. Here is how to find out why the best claim settlement ratio in health insurance matters:

Assess Insurer’s Credibility

A high health insurance claim settlement ratio, usually above 95%, indicates an insurer's proven strong record of honouring claims promptly. This reflects building trust among customers and maintaining strong financial health.

Faster Claim Approval

During medical emergencies, claim rejections and payment delays are the last thing that concerns you. If there is a high claim settlement ratio, you gain confidence in managing your expenses promptly, minimising financial stress.

Informed Decision Making

Annually, the IRDAI publishes claim settlement ratio data to let customers compare between insurers before finalising a plan. For instance, according to the Economic Times, the majority of the insurers have maintained a claim settlement ratio of 95% above, which indicates a high claim settlement performance.

Financial Security

A good claim settlement ratio indicates that the healthcare costs will be covered on time, resulting in reduced out-of-pocket expenses.

Choose Bajaj General Insurance for a trustworthy health insurance with a strong record of claim settlement ratio and comprehensive coverage tailored according to your needs.

What is a Good Health Insurance Claim Settlement Ratio?

There’s no fixed benchmark for a “perfect” claim settlement ratio, but generally, a claim settlement ratio above 85% is considered acceptable, while anything over 90% is deemed to be considerable. Insurers with claim settlement ratios of 95% or higher often demonstrate outstanding claim performance and strong credibility.

A rising claim settlement ratio usually indicates that an insurer is settling a greater share of claims, a clear sign of trustworthiness.

However, the health insurance claim settlement ratio alone does not tell the full story. It does not reflect how fast claims are settled, the reasons behind claim rejections, or whether approved claims were paid without delays. For example, an insurer may boast a high claim settlement ratio, but complex hospitalisation claims might still take time to process.

Also Read: The Incurred Claims Ratio (ICR) in Medical Insurance: Complete Guide

5 Tips to Choose a Health Insurance Provider With a High Claim Settlement Ratio

Follow the tips below to choose a health insurance provider with a high claim settlement ratio:

1. Aim for a claim settlement ratio of at least 90% as a basic benchmark, but if you want extra assurance, prefer insurers with a claim settlement ratio of 95% or above.

2. Always check the insurer’s public disclosures or refer to the IRDAI handbook for the most accurate and updated figures.

3. Review the reasons for claim rejections, average settlement time, and customer feedback to gain a clear understanding of the insurer’s claim process.

4. Compare the claim settlement ratio across multiple years instead of relying on a single year’s figure. Consistent performance over time can indicate stable claim-handling practices and may provide a more balanced view of the insurer’s reliability.

5. Even insurers with a high claim settlement ratio may have conditions that affect claim approval, making policy terms equally important during selection. So make sure to read the policy wording carefully for all the details.

How to Calculate Health Insurance Claim Settlement Ratio?

Understanding how to calculate the health insurance settlement ratio helps in assessing the reliability of an insurer more accurately. Claim settlement ratio not only reflects a number, but it showcases the fairness, efficiency and commitment of health insurance companies' claim settlement when required the most.

The health insurance claim settlement ratio formula is simple:

claim settlement ratio = (Total Number of Settled Claims) / (Outstanding Claims at Beginning + Total Number of Settled Claims – Outstanding Claims at End) *100

This ratio is calculated for each financial year, usually from April to March, and is expressed as a percentage. A higher claim settlement ratio indicates that the insurer has settled a larger proportion of claims compared to the total number received.

However, do not rely solely on the claim settlement ratio. Also consider the claim volume, average settlement timeline, and the nature of claims to get a complete picture of an insurer’s reliability.

To understand the formula, consider an example.

1. Outstanding claim at the beginning: 2,000

2. Total received claims: 15,000

3. Total number of settled claims: 13,000

4. Outstanding claims at the end: 1,300

Applying these to the formula,

Claim settlement ratio = (13,000 / (2,000+13,000-1,300))*100 = 94.8%

This ratio indicates the insurer has approved and settled 94.8% of claims submitted during that year.

Top 10 Health Insurance Providers in India Based on Claim Settlement Ratio of 2024-25

To know which health insurance has the highest settlement ratio, you can follow the table below:

Disclaimer: The above percentage of claims paid in less than 3 months during 2024-25.

Also Read: Critical Illness Policy Comparison in India

How to Check the Claim Settlement Ratio of Health Insurance Companies?

Before you opt for any health insurance company, make sure to verify its claim settlement ratio from trustworthy sources. Here is how you can check the health insurance claim settlement ratio of a company:

Using the IRDAI’s Annual Report

The IRDAI's annual report comprises the claim settlement ratio of health insurance companies. You can navigate this data under the “Handbook of Insurance Statistics” section located on the IRDAI official website. The report includes:

1. Number of claims settled

2. Total number of claims received

3. Claim amount ratio

4. Number of outstanding claims

IRDAI is one of the most reliable and authentic sources for comparing the claim settlement ratios of different companies.

Third-party Rating Websites

The majority of the third-party rating websites compile the claim settlement ratio ranking and offer the best one across different providers. Thus, always ensure to cross-check the claim settlement ratio-related data with official figures published by IRDAI for accuracy.

Comparing Directly on Insurers’ Websites

There are many reputable insurers nowadays, displaying their claim settlement ratios directly on their official brochures and websites. This transparency lets you purchase health insurance plans with confidence. Also, these portals provide customer reviews and let you assess user experiences besides the claim settlement ratio.

Factors Affecting Claim Settlement Ratios in Health Insurance

Complexity in Claim Process

The complexity of the claim procedure is a prime determinant of the number of claims settled. Bajaj General Insurance designs the claim process as both cashless and reimbursement.

For the designed streamlined process, there is reduced complexity, which also affects the settlement ratio positively. Conversely, if there is any lack of clarity or delay in the claim process, the ratio will reduce.

Strength of Hospital Network

A comprehensive and well-managed network of hospitals is crucial as it enables policyholders to avoid the hassles of reimbursement. With a robust network, the insurer can deliver cashless services efficiently, thereby boosting the overall performance of claim settlement.

Underwriting and Evaluation of Risk

Insurers conducting robust risk assessment during the initial stages of policy issuance tend to face fewer claim-related issues. With prompt and accurate underwriting, the number of claim rejections also reduces significantly. Whereas a rigorous underwriting process possesses high-risk claims and thereby maintains a high settlement ratio.

Mechanism of Grievance Redressal

Insurers comprising reliable and efficient teams with the capability of faster dispute resolution are found to close claims without escalation. This leads to fewer rejected claims, raising the health insurance claim settlement ratio and customer satisfaction.

Digital Infrastructure

The introduction of modernised digital infrastructure significantly reduces the chances of manual errors. It also speeds up claim processing, leading to a high settlement ratio. With the official online portal of Bajaj General Insurance, policyholders can complete the claim registration process and check the status instantly.

Also Read: Best Claim Settlement Ratio in Health Insurance

What are the Types of Health Insurance Claim Settlement Processes?

The two different types of health insurance claim settlement processes include cashless claim settlement and reimbursement claim. Let us break them down:

Cashless Claim Settlement

With a cashless claim, Bajaj General Insurance offers policyholders cashless treatment within a network of over 18,400+ hospitals across India. Here, individual policyholders receive quality treatment without paying upfront. If you are treated at any of the network hospitals, the insurer contacts the hospital for bill settlement instantly.

Here are the steps you must follow if you are opting for a cashless claim from Bajaj General Insurance:

Step 1: Choose any hospital within the network of Bajaj General Insurance to experience a cashless claim facility.

Step 2: The details you have provided will undergo verification, and further, the hospital sends the pre-authorised form to the Bajaj General Health Administration Team (HAT).

Step 3: The details of the pre-authorisation request will be further verified with policy benefits and informed to the healthcare provider within 1 working day.

Step 4: Once approved, the initial response will be sent to your healthcare provider, usually within 60 minutes.

Step 5: The treatment costs get settled instantly, and you need not worry about meeting the medical bills.

Reimbursement Claim Settlement

For reimbursement claim settlement, you receive treatment from any non-network hospital. In this case, it is mandatory to pay the bills first and then receive the reimbursement amount later on.

Follow the steps below if you are qualified for a reimbursement claim with Bajaj General Insurance:

Step 1: Keep all your hospitalisation-related documents ready and submit them individually to the Bajaj General HAT.

Step 2: Bajaj General Insurance carries out a mandatory verification process for the required documents.

Step 3: In case there are any documents missing, the insured individual is notified beforehand to provide further relevant information.

Step 4: Completing the enquiry process, you can initiate the claim settlement process and proceed with releasing the payment through ECS within 10 working days (subject to terms and conditions).

Step 5: After claim approval, your submitted documents are verified again, and if permitted, Bajaj General Insurance releases the payment within 7 working days through ECS.

Documents Required for Health Insurance Claim Settlement

Here are the documents required to obtain the best health insurance claim settlement ratio:

1. Hospitalisation claim form duly filled in and also signed by the insurer

2. Original paid receipts

3. Original copy of the discharge summary

4. Original copy of hospital bill with a detailed breakdown of costs

5. All kinds of lab and test reports

6. A copy of the invoice/sticker/barcode

7. KYC form

8. First letter of consultation from the doctor

9. Duly filled and signed NEFT form from the proposer or policyholder

Also Read: List of Documents Required for Health Insurance

Bottom Line

Overall, the health insurance claim settlement ratio is an effective indicator of performance by insurance companies. While you focus on examining the claim ratio of health insurance companies, consider a claim settlement ratio of 90% or more.

A high claim settlement ratio also reflects a strong record of health insurance companies’ performance in terms of paying claims.

Checking a claim settlement ratio helps you choose a reliable health insurance policy. Choose the comprehensive health insurance plans from Bajaj General Insurance, since it has one of the best claim settlement ratios for health insurance in 2026.

Frequently Asked Questions

What is the difference between the claim settlement ratio and the incurred claim ratio?

The health insurance claim settlement ratio reflects the percentage of settled claims out of total received claims. On the other hand, the incurred claim ratio compares the total paid amount to the collected premium amount. The claim settlement ratio is a good measure of efficiency, while ICR measures financial health.

How can I improve my chances of successful claim settlement?

To improve chances of successful claim settlement, make sure to provide up-to-date information while purchasing the policy, disclose any pre-existing diseases, submit all relevant documents and inform the insurer immediately after being hospitalised. Maintaining a clear medical record prevents claim delay and rejections.

Where can I find updated claim settlement ratio data?

You can find the updated health insurance claim settlement ratio data from the annual report published by the IRDAI. There are also other insurance company websites publishing claim settlement ratio data to maintain transparency.

What factors cause claim rejections?

The major factors causing claim rejections include misleading information, not disclosing pre-existing diseases, expired policy, or any treatment not included under the chosen plan. Going through the terms and conditions of the policy helps overcome these issues.

How long does claim settlement usually take?

Health insurance claim settlement generally takes up to 30 days, depending on the insurer and claim type. Cashless claims are usually processed faster, while reimbursement claims may take longer due to document verification and approval procedures.

Standard T&C apply. Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.

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