Care Health Insurance offers various health insurance policies in the retail and group segments, such as comprehensive health insurance, top-up coverage, personal accident, maternity, critical illness, micro insurance, and wellness services. The company has been awarded and recognised for its excellence in customer service, product innovation, and value-for-money services.
One of the important indicators of the company’s performance and reliability is its claim settlement ratio (CSR), which reflects the proportion of claims that the company has settled from the total claims received in a financial year. In this article, we will discuss how to calculate the claim ratio of Care Health Insurance, the claims process and documents required to file a claim.
How is health insurance claim ratio calculated?
The claim ratio of health insurance companies can be measured by different ratios:
Claim Settlement Ratio (CSR)
It is the ratio of claims settled by a health insurance company against the total claims filed in a particular financial period. It helps in weighing the capability of the insurer to handle customer’s claims. The formula for CSR is:
CSR = (Total claims settled / Total claims filed) x 100
Incurred Claim Ratio (ICR)
It is the ratio of the total claims that insurance company has paid divided by the total sum of premium collected during the same period. It indicates the profitability and solvency of the insurer. The formula for ICR is:
ICR = (Total claims paid / Total premium collected) x 100
Insured Claims Ratio (ICR)
It is the ratio of the total claim amount paid by the health insurance company to the total premium amount collected in a financial year. It reflects the underwriting efficiency and risk management of the insurer. The formula for ICR is:
ICR = (Total claim amount paid / Total premium amount collected) x 100
Claim process of Care Health Insurance
Care Health Insurance ensures smooth settlement of cashless as well as reimbursement claims. The claim process involves the following steps:
Claim intimation: The policyholder or the nominee should inform the customer care team of the insurer within 24 hours of an emergency hospitalisation and at least 48 hours before a planned hospitalisation. The claim intimation can be done through the toll-free number, email, website, or mobile app of the insurer.
Pre-authorisation process: For cashless claims, the policyholder or the nominee should submit the filled-in pre-authorisation form at the hospital’s insurance desk. The hospital will send the form to the insurer and seek cashless treatment approval. For reimbursement claims, the policyholder or the nominee should pay the hospital bills and collect all the relevant documents.
Processing of claim request: The in-house claim management team of the insurer will review the claim request and accept or reject it based on the policy terms and conditions. The insurer will communicate the decision to the policyholder or the nominee through SMS, email, or letter.
Claim settlement: For cashless claims, the insurer will pay the claim amount directly to the network hospital after deducting any non-payable expenses or co-payments. For reimbursement claims, the policyholder or the nominee should submit the original documents to the insurer within 15 days of discharge. The insurer will reimburse the claim amount after verifying the documents and deducting any non-payable expenses or co-payments.
Claim process for Care Health Insurance offered through Bajaj Finance
In case you want to claim benefits of a Care Health Insurance policy offered through Bajaj Finance, you can follow the steps given below:
Cashless claim:
Step 1: Call the toll-free number 1800-102-4488 or write to the insurance provider at customerfirst@careinsurance.com.
Step 2: Look for the cashless hospital nearest to you.
Step 3: Contact hospital insurance helpdesk or billing counter with a copy of patient’s medical ID card (issued by the insurer), pre-authorisation form along with valid Government ID proof.
Step 4: Fill in the pre-authorisation form online or at the hospital desk.
Step 5: The hospital/TPA submits the post treatment discharge summary and other related documents to the insurer for final approval.
Reimbursement claim:
Step 1: Call the toll-free number 1800-102-4488 or write to the insurance provider at customerfirst@careinsurance.com.
Step 2: Settle all medical bills and other costs involved in hospitalisation and treatment at the hospital.
Step 3: Submit the required documents like the reimbursement claim form, hospital discharge summary, bills, and prescriptions online on the insurer’s website.
Step 4: The insurer will review and verify the documents and process the claim as per the policy's terms and conditions.
Documents required for Care Health Insurance claims
The policyholder or the nominee should submit the following documents for filing a claim with Care Health Insurance:
- Duly filled and signed claim form
- Valid identity proof of the policyholder or the nominee
- Original discharge summary from the hospital
- Original final hospital bill with item-wise break-up
- Original paid receipt against the final hospital bill
- Original pharmacy bills and prescriptions
- Original investigation reports and bills
- Attested copy of indoor case papers
- In case of implant surgery, invoice and sticker of the implant
- In case of accidental cases, FIR or MLC report
- In case of death claims, death certificate, post-mortem report, and legal heir certificate
- A cancelled cheque or NEFT details of the policyholder or the nominee
- KYC documents for claims amounting to Rs. 1 lakh or above
