Health Insurance Claims– The average payout per claim was Rs 31,086 in FY 2024. In claim settlement, 72% of the claims were settled through third party administrators, while 28% of the claims were settled through the company’s in-house system.
In the financial year 2024, out of 100 policy holders who claimed health insurance, only 82 were paid by the insurance companies. 18 percent of the claims were rejected. Insurance regulator IRDAI has given this information. According to the report of the insurance regulator, 3 crore claims worth ₹ 1.1 lakh crore were registered. Apart from this, there were also 17.9 lakh pending claims of ₹ 6,290 crore from previous years.
Out of the total claims, insurers settled about 2.7 crore claims and paid ₹ 83,493 crore to the policyholders. If seen in terms of volume, insurance companies settled 82% of the claims and gave money to the policyholder. In terms of value, this figure represents 71.3%. Of the claims that were not paid, claims worth ₹15,100 crore were declared “invalid as per the terms and conditions of the policy contract”.
Insurance companies collected ₹1.1 lakh crore as health insurance premium in FY24. At the same time, claims worth ₹83,493 crore were paid. The highest premium was collected by public sector insurers. Government companies deposited ₹40,993 crore in this item. At the same time, private companies collected ₹34,503 crore and standalone health insurers collected ₹32,180 crore premium.
Average claim payment was Rs 31,086
The average payment per claim was Rs 31,086. In claim settlement, 72% of claims were settled through TPAs (Third Party Administrators), while 28% of claims were settled through the company’s in-house system. Talking about the mode of payment, 66.16% of claims were settled in cashless mode. At the same time, 39% of claims were settled in reimbursement mode.
36 lakh claims rejected
36 lakh claims worth ₹10,937 crore were rejected or denied by insurance companies. 20 lakh claims worth ₹7,584 crore are still pending. Rejected claims are those which are rejected after verification of documents. Meanwhile, the Insurance Ombudsman Office received 34,336 complaints related to health insurance this year. At the same time, 2,846 complaints were pending from previous years. Of these, 6,235 complaints were decided in favor of the policyholder. The highest number of complaints were received from Mumbai, Pune, Ahmedabad and Chandigarh.
