Table of Contents
- What is the Claim Settlement Ratio
- How is the Health Insurance Claim Settlement Ratio Calculated
- Why Is the Claim Settlement Ratio Important When Choosing an Insurance Provider
- Claim Settlement Ratio of Health Insurance Companies
- Top 10 Health Insurance Companies in India by Claim Settlement Ratio 2026
- Health Insurance Claim Settlement Process
- Why Do Claims Get Rejected?
- How Group Claims are Settled Faster?
- Documents Required for Claim Settlement
- Factors Affecting the Claim Settlement Ratio of an Insurance Company
- How to Check the Claim Settlement Ratio of Health Insurance Companies?
- How Do You Choose a Health Insurer with a High Settlement Ratio?
- Conclusion
- FAQs
Claim Settlement Ratio (CSR) in the health insurance industry is a critical metric that reveals the percentage of claims settled by an insurer compared to the total claims received in a financial year. A good CSR is typically between 95% and 100%, reflecting the company’s ability to settle claims efficiently and effectively.
The Claim Settlement Ratio is a direct indication of trust in the insurance sector, showcasing the insurer’s reliability and commitment to policyholders. Policyholders need to consider the CSR of an insurance company before purchasing a policy, as it reflects the company’s claim support and settlement track record.
A high Claim settlement ratio signifies a high claim-settling ability, providing policyholders with confidence in the insurer’s reliability and financial stability.
What is the Claim Settlement Ratio
The term “claim settlement ratio” typically refers to the ratio of the number of claims paid by an insurance company to the total number of claims received by the company within a specific period. The claim settlement ratio can vary across different types of insurance, such as life insurance, health insurance, or general insurance.
According to the IRDAI Annual Report during the Financial Year 2022-23, the aggregate net incurred claims for the insurance industry saw an increase of 6.22 per cent over the previous year, amounting to Rs 1,49,313 crore ( Rs 1,40,566 crore during the previous year).
How is the Health Insurance Claim Settlement Ratio Calculated
The health insurance claim settlement ratio is calculated by dividing the total number of claims settled or paid by the insurance company by the total number of claims received, including any outstanding claims at the beginning of the year. The formula for arriving at the claim settlement ratio is as follows:
Claim Settlement Ratio or CSR =Total claims settled or paid/total claims received + any outstanding claims at the start of the year
For example, if a health insurance provider settles 90 out of 100 claims made by its customers in a certain year, the CSR would be 90%. If in the following year the same insurer settles 250 out of 290 claims made and has 10 outstanding claims from the prior year, the calculation for the CSR would be as follows:
CSR=(250/290+10)×100=83.33%.
Why Is the Claim Settlement Ratio Important When Choosing an Insurance Provider
The claim settlement ratio is an essential factor to consider when choosing an insurance provider for several reasons. Here are a few of the reasons:
1. Reliability and trustworthiness
A high claim settlement ratio reveals that the insurance company has a track record of settling a significant portion of the claims it receives. This demonstrates confidence that claims are likely to be settled promptly and fairly when needed, which means reliability and trustworthiness.
2. Customer service
Health insurance companies with high claim settlement ratios typically have efficient and responsive claims processing systems in place. They prioritise customer satisfaction by handling claims efficiently, providing support throughout the claims process, and addressing policyholders’ concerns promptly.
3. Financial stability
A high CSR is often indicative of the financial stability and strength of an insurance company. It suggests that the company has sufficient resources to honour its obligations and pay out claims, even during challenging economic conditions.
4. Peace of mind
Knowing that an insurance provider has a high claim settlement ratio can provide policyholders with peace of mind. This helps alleviate worries about potential claim denials or delays during times of illness, accidents, or emergencies.
5. Comparison tool
The CSR serves as a useful tool for comparing different insurance providers and their performance in settling claims. Policyholders can use this information to make informed decisions and choose insurance companies that demonstrate a strong commitment to honouring obligations.
Claim Settlement Ratio of Health Insurance Companies
The CSR for health insurance companies in India varies, with different insurers having different ratios. In fact, companies that were top of the list in a particular year could tend to drop lower in the subsequent years and those that were lower could rank higher. The CSR tends to vary according to many other factors.
In India, there are government regulations that require health insurance companies to disclose their claim settlement ratio. The Insurance Regulatory and Development Authority of India (IRDAI) mandates all insurance companies, including health insurers, to disclose their claim settlement ratios annually.
Top 10 Health Insurance Companies in India by Claim Settlement Ratio 2026
Here we have listed the top 10 health insurance companies that have a high Claim Settlement Ratio, providing efficiency in settling claims and offering reliable services to customers.
Read More: Top 10 Health Insurance Companies In India 2026
| Rank | Insurer Name | Claim Settlement Ratio (2024-2025) |
|---|---|---|
| 1 | Aditya Birla Health Insurance Co. Ltd. | 100 |
| 2 | Galaxy Health Insurance Co. Ltd. | 100 |
| 3 | Narayana Insurance Co. Ltd. | 100 |
| 4 | Niva Bupa Insurance Co. Ltd. | 100 |
| 5 | Acko General Insurance Ltd | 99.98 |
| 6 | Care Health Insurance Ltd. | 99.95 |
| 7 | ManipalCigna Health Insurance Co. Ltd. | 99.88 |
| 8 | Reliance General Insurance Co. Ltd. | 99.32 |
| 9 | Zurich Kotak General Insurance Co.(India) Ltd. | 98.12 |
| 10 | Go Digit General Insurance Ltd. | 96.91 |
Onsurity is partnered with leading insurance providers like Reliance General Insurance, Go Digit, and Zurich Kotak General Insurance to bring Onsurity members reliable, comprehensive coverage.
Health Insurance Claim Settlement Process
The health insurance claim settlement process involves several steps that policyholders must follow to ensure efficient and hassle-free claim settlement. Here are the key points, depending on whether it is a cashless settlement process or a reimbursement process.
1. Cashless Claim Settlement Process (Step by Step)
Understanding how the cashless claim process works ensures a smooth hospitalization experience without any upfront payments.
- Inform the insurer at least 2 days before planned hospitalisation or within 24 hours in case of emergency. Provide the necessary details like policy number, patient name, hospital name, reason for hospitalisation, etc.
- The hospital will contact the insurer and send a pre-authorisation form to initiate the claim settlement process. The insurer will verify the policy details and coverage to issue an initial authorization email within 1 hour as per IRDAI guidelines.
- The insurer will approve the cashless facility if the treatment is covered under the policy terms and conditions. If any additional information is required, the insurer may take some time to approve the claim. Once the claim is approved, the hospital will provide treatment to the patient.
- At the time of discharge, the hospital will send the final bill to the insurer. The insurer will settle the approved amount directly with the hospital within 3 hours to initiate a prompt exit.
- The patient may need to pay any non-payable items, co-payments, or deductibles as per the policy terms. The hospital may take a small advance for this purpose.
- The patient should obtain documents like the final bill, payment receipt, discharge summary, etc., from the hospital.
2. Reimbursement Claim Settlement Process (Step by Step)
If you receive treatment at a non-network hospital or pay your medical bills upfront, you can initiate a reimbursement claim settlement process.
- Inform the insurance company within 7-15 days of discharge from the hospital. Provide the necessary details like policy number, patient name, hospital name, reason for hospitalisation, etc.
- Pay the hospital bills upfront and collect all the original documents on the day of discharge like discharge summary, hospital bills with detailed breakup, paid receipts, lab reports, first consultation letter, etc.
- Fill out the reimbursement claim form available on the insurance company’s official website or app. Provide the required information accurately.
- Submit the duly filled claim form along with the original documents to the insurance company 15-20 days post-discharge. You can submit it online or send physical copies via registered post.
- The insurance company will verify the claim and documents. If any additional information is required, they will reach out to you within 15 days of document submission.
- Once the claim is approved, the insurance company will settle the claim amount by crediting it to your bank account. The turnaround time is generally 30 days from the date of receiving all documents.
Why Do Claims Get Rejected?
Receiving a claim rejection letter, especially while recovering or managing a loved one’s hospital treatment, can be terrifying and disheartening.
Take a deep breath. Understand that a claim rejection or denial is often procedural rather than final, and many rejections can be resolved and prevented if you understand the various triggers the system flags. Under the IRDAI guidelines, insurers are required to state the exact policy cause behind any rejection, giving you a clear path to identify the issue.
Here are some reasons health insurance claims are rejected in India and how to prevent these issues from arising:
1. Non-Disclosure of Pre-Existing Diseases (PED)
The insurer’s review team checked your previous hospital records and medical history and flagged a previously existing condition such as hypertension, thyroid, diabetes, etc, which was not listed on your original proposal form.
To prevent this from happening, we need to declare all previous medical diagnoses, surgeries, or routine procedures during the policy enrollment itself, even if it's minor and occurred years ago.
2. Missing or Incomplete Documentation
An important document such as a diagnostic report, pharmacy invoice, original bill, or signed claim was not included in the submission packet.
To avoid this, before sending original or digital copies, cross-reference your submission packet with the insurer’s required document checklist.
3. Active Waiting Period
The claim was made during an active waiting period such as the standard 30-day initial waiting period, the 24-48 months waiting period for PED, or the 24-month specific-procedure waiting period for cataract, hernia, joint replacement, etc.
To prevent this from happening, you need to check your policy schedule to ensure there are no active waiting periods before scheduling any elective procedures.
4. Room Rent Capping Breach
This might occur if you selected a hospital room category that exceeded the policy’s daily room rent limit.
To avoid this, confirm the room rent limit before admission. Opting for a higher room rent will lead to cascading proportionate, where doctor fees, nursing, and OT charges will also increase.
5. Delay in Claim Initiation
The insurer was not notified about the hospitalization within the stipulated time frame, which is 24 hours in case of emergencies, and 48 hours in terms of planned hospitalization.
To prevent this from happening, save your insurer’s toll-free number and email address on your phone or ask your family member to send an email intimation immediately upon admission.
According to IRDAI guidelines, insurers can not reject claims solely because of procedural delays if the delay is justified. You can submit a written explanation detailing the emergency and signed by the primary caregiver.
6. Consumables Exclusion
Health insurance policies are designed to include essential medical costs such as doctor fees, nursing, medicines, etc. While, non-medical consumables, comfort expenditure, and administrative fees are not generally included in the policy.
To avoid this, be aware that standard health policies exclude non-payable expenses and general administrative fees unless you have a specific consumables cover rider attached to your policy.
7. Lack of Established “Medical Necessity”
This happens when the insurer’s medical panel declares that the treatment could have been performed in an outpatient (OPD) facility without requiring a 24-hour inpatient admission.
This can be prevented by avoiding overnight hospital stays for routine diagnostic checkups, health screenings, or oral medication monitoring.
How Group Claims are Settled Faster?
The reasons for claim rejection mentioned above are largely a retail problem. In a group setup, these problems are generally settled. Employees are typically enrolled without individual medical tests, so there is no proposal form to go wrong. Similarly, many group insurance plans offer coverage for day 1, which waives standard and PED waiting periods.
The HR, along with the insurer’s official platform, helps raise and track claims; as a result, fewer files are stalled due to missing documents. Additionally, group insurance has standardized or high room rent limits, which prevent employees from unexpected-out-of-pocket costs and cascading proportional deductions.
For an employer, claim settlement ratio is not the metric that matters most; it is how smoothly and efficiently the team is treated and reimbursed. Delivering a supported claim experience is one of the strongest reasons to invest in group health insurance for employees rather than leaving staff to navigate the retail route on their own.
Documents Required for Claim Settlement
Here are the key documents required for claim settlement in health insurance:
1. For Cashless Claims
- Health Insurance e-card
- Government photo ID proof of the patient and the primary member
- PAN Card
- Doctor consultation papers and prescriptions
- Medical documents and investigation records
The hospital will directly coordinate with the insurance company and submit the necessary documents. The patient only needs to provide ID proofs and insurance details.
2. For Reimbursement Claims
- Duly filled claim form provided by the insurance company
- KYC - Photo ID
- Bank details with cancelled cheque
Factors Affecting the Claim Settlement Ratio of an Insurance Company
Factors affecting the claim settlement ratio of an insurance company include:
1. Efficiency of the insurance company
Insurers with an efficient and clear system for claim assessment, verification, and settlement are more likely to have a higher CSR. Streamlined processes ensure that claims are settled promptly and accurately, which in turn leads to higher customer satisfaction.
2. Policyholder’s adherence to terms and conditions
Policyholders must abide by the terms and conditions outlined in their insurance policies. This includes timely premium payments and providing accurate information during the application process. If terms and conditions are not followed, it affects the claim settlement process and leads to unnecessary administrative hassle.
3. Disclosure of material facts
The insured must disclose all material facts about their health, their occupation, income, previous coverage details accurately in the proposal form while availing the insurance. This ensures that no unnecessary delays occur while processing claims.
4. Claims’ value
The value of claims settled by an insurer is also important, along with a high CSR. A high CSR isn’t reflective of the size of the claims settled, so understanding the total claim amount is essential for a comprehensive evaluation of the insurer’s reliability.
How to Check the Claim Settlement Ratio of Health Insurance Companies?
To check the claim settlement ratio of health insurance companies, you can follow one or all of these methods:
1. IRDAI Report
The Insurance Regulatory and Development Authority of India releases an annual report that includes the claim settlement ratios of different insurance companies in India. You can access this report to compare the claim settlement ratios of various health insurance providers and choose a reputable insurer with a high ratio.
2. IBAI Report
The Insurance Brokers Association of India also releases annual reports that contain information on the claim settlement ratios of insurance companies in India.
3. Insurer’s Website
Most insurance companies in India publish their claim settlement ratios on their official websites. By visiting the websites of different insurance providers, you can easily check and compare their claim settlement ratios to determine the reliability of the insurer in settling claims.
How Do You Choose a Health Insurer with a High Settlement Ratio?
To choose an insurer with a high CSR, follow these steps:
1. Research
Research different insurers and their Claim Settlement Ratios. Try to find insurers that have a consistently high CSR.
2. Consider incurred claim ratio
In addition to the claim settlement ratio, consider the Incurred Claim Ratio (ICR) of insurers. The ICR reflects the percentage of total claims paid to the total premium received by an insurer in a given fiscal year. A lower ICR indicates a higher likelihood of receiving a higher claim amount when needed.
3. Evaluate customer reviews
Look for customer reviews and feedback regarding the claim settlement process of different insurers. Positive reviews indicating smooth and hassle-free claim settlements can help you choose an insurer with a good settlement ratio.
4. Compare benefits and features
Compare the benefits, network hospitals, and coverage offered by different insurers. Choose an insurance provider that not only offers a high claim settlement ratio but also provides comprehensive coverage and health benefits according to your healthcare needs.
Conclusion
To sum it up, a high Claim Settlement Ratio is a crucial metric that people need to consider before they choose a health insurance provider. A high CSR shows policyholders that the insurance provider can consistently settle claims, which offers them peace of mind and financial security.
Additionally, the Claim Settlement Ratio helps policyholders assess the insurer’s track record, customer service quality, and overall performance in claim settlement over time.
FAQs
1. Which insurer has the best claim settlement ratio 2026?
Aditya Birla Health Insurance Co. Ltd. has the best claims settlement ratio in 2026.
2. How long does claim settlement take?
3. What to do if claim is rejected?
If the claim is rejected, obtain the written rejection letter with the specific policy reason for the rejection. Gather supporting evidence like missing hospital bills, doctor’s written certificate citing medical emergency, and file a written appeal with the insurer’s Grievance Redressal Officer (GRO) who is mandated to respond within 15 days. If unresolved, you can address the matter through IRDAI’s Bima Bharosa portal or file a free complaint through Insurance Ombudsman for a legally binding resolution.
4. Which is the No 1 health insurance in India?
It’s difficult to pinpoint any particular company or product, as there are various factors that can determine the No 1 health insurance in India. However, Onsurity is pioneering monthly subscription-led employee healthcare benefits and has achieved a significant milestone by serving over a million lives across more than 5,000 businesses within just three years of its inception.
5. What is a good claim settlement ratio?
A good claim settlement ratio in health insurance typically falls within the range of 95% to 100%.
6. Who are the top 5 health insurance companies?
There are various parameters that can determine the top 5 health companies, and no one company has all the best parameters.
7. How can policyholders verify the claim settlement ratio of an insurance company?
Policyholders can verify the CSR of an insurance company through the IRDAI Annual Report or through the respective company website.
8. Is the claim settlement ratio the only factor to consider when selecting an insurance provider?
No. There are other factors that one can consider like network hospitals, coverage benefits, incurred claims ratio, customer service, etc.
9. Can an insurance company improve its claim settlement ratio over time?
Yes, an insurance company can improve its CSR over time through various strategies and initiatives.
