HDFC ERGO Health Insurance Claim Settlement Ratio

When choosing a health insurance policy, you seek comprehensive plans with great features and minimum restrictions,sub-limits and clauses. However, finding such wholesome policies with guaranteed chances of claim settlement from a credible provider - is a tough combination to find.

HDFC ERGO Health Insurance is one such rare find. This stable has it all - from comprehensive plans to the great credibility of the insurer. Now, health insurance plans from HDFC ERGO have gained massive popularity among its policyholders. On the other hand, you need to consider whether HDFC ERGO is a health insurer with a consistent track record. Is the insurer’s credibility as strong in data as in the market?

Let’s examine one such metric used to analyse the insurer’s credibility - the HDFC ERGO Health Insurance Claim Settlement Ratio.

What is the Claim Settlement Ratio?

The Claim Settlement Ratio of a health insurance provider is calculated by -

(The total number of claims settled in a  year by an insurer / The total number of claims filed to the insurer across the year) * 100

For any top-notch health insurance provider, the CSR is 90 and above (but not above 100). On the other hand, with insurers that have delays in their claim settlement, you will be looking at a claim settlement ratio of 100 and above. Again, if an insurer's CSR is below 80, this indicates that the provider is rejecting more claims than expected. Neither of these cases is suitable, so such insurers must be avoided.

What is the HDFC ERGO Health Insurance Claim Settlement Ratio for 2024?

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(Please remember that if you're seeking the HDFC ERGO Health Insurance Claim Settlement Ratio for 2024, you must examine its CSR for the previous financial year: 2022 to 2023. However, relying solely on data from one year is insufficient since it doesn't allow for an evaluation of the insurer's consistency in claim settlement. Therefore, we have collected the HDFC ERGO Health Insurance Claim Settlement Ratio data for the past 3 years: 2020 to 2023. Subsequently, we calculated the average of these three years and compared it against the industry average for the same period.)

Overview of HDFC Ergo Health Insurance

What is the significance of HDFC ERGO Health Insurance Claim Settlement Ratio 2024?

Considering that you have had a look at the numbers for the HDFC ERGO Health Insurance Claim Settlement Ratio, let’s now draw an insight into the insurer’s credibility based on these numbers -

1. Consistency: HDFC Ergo Health Insurance is quite possibly one of the most consistent providers in the industry. From 2020 to 2023, the insurer has consistently kept its CSR numbers not just over the 90% threshold but over 95%. Needless to say, HDFC ERGO Health Insurance has one of the best CSRs in the industry.
2. Overall Performance: The HDFC ERGO Claim Settlement Ratio has been beating the industry average year-on-year and the average of CSRs from 2020 - 2023. The numbers are incredible and an excellent sign for the brand’s existing and potential policyholders.

Why is the Claim Settlement Ratio important?

The Claim Settlement Ratio, or CSR, of an insurer, is one of the crucial metrics used to analyse its credibility. While it isn’t the only determining metric, CSR also has a vital role—it helps you analyse the insurer's claim settlement intent by offering insight into the number of claims rejected and settled.

Unfortunately, an insurer’s CSR does not reflect whether the insurer could settle the claim in time and in full. Often, insurers settle multiple partial claims and more minor claims to game their CSR numbers, which might be pretty misleading for potential policyholders. Thus, when choosing an insurer, make sure to take a look at its Incurred Claim Ratio, complaint volume, and number of partner hospitals.

What is the Claim Settlement Process for HDFC ERGO Health Insurance?

• CASHLESS

Contact HDFC ERGO Health Insurance 48 hours before the hospitalisation (planned treatment) or within 24 hours of hospitalisation (emergency hospitalisation) via the hospital insurance desk.

STEP 1: Register your claim on the official site of HDFC ERGO Health Insurance and fill in the required details.

STEP 2: Submit the required documents (as mentioned below).

STEP 3: The hospital will request the insurer for their pre-authorisation approval.

STEP 4: The insurer approves the treatment, and you can go ahead with a cashless mode of claim settlement, which will be covered by your insurer when you are discharged.

(You can still proceed with the treatment if your cashless request is denied. You will need to pay the bill from your pocket initially and can later file for a reimbursement claim settlement. The process for this is mentioned below.)

• REIMBURSEMENT

STEP 1: You can register your claim online by visiting the official site of HDFC ERGO Health Insurance

STEP 2: Complete the claim form and submit it with the required documents (as listed below) online or at the nearest branch.

STEP 3: After cross-verification of your documents and the hospital desk, the insurer will disburse your claim amount to your bank account.

You can also receive guidance on your claim settlement by calling their helpline number 022 6234 6234 - for assistance.

What are the documents required to settle claims for HDFC ERGO Health Insurance?

When planning to file a claim to HDFC ERGO Health Insurance, make sure you have the soft/hard (online/offline process) copies of the following documents handy -

1. CASHLESS

• Policy number (health insurance card)
• Copy of ID proof

2. REIMBURSEMENT

• Copy of duly filled Claim form
• Copy of ID proof of the patient
• Copy of Aadhar and PAN of the proposer
• Copy of Discharge summary
• Copy of investigation reports confirming diagnosis and all doctor consultation papers
• Copy of final bill with detailed breakup
• Copy of payment receipt against the payment made
• Copy of  cancelled cheque bearing  pre-printed name of the proposer on it or copy of last 3 months bank statement of the proposer bearing bank account number and IFSC code or copy of the first page of bank passbook of the proposer showing bank account details

Please note: Based on the underwriter’s decision, you may be required to submit some additional documents.

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Conclusion

From the best health insurance plans (like HDFC Ergo Optima Super Secure / Secure, HDFC Ergo Optima Restore, HDFC Ergo myHealth Suraksha Gold, and more) in the industry to the best features and industry-best numbers across Claim Settlement Ratio, complaint volume, Incurred Claim Ratio, and partner hospitals - HDFC ERGO has it all. If you don’t mind the slightly higher premiums, HDFC ERGO is a solid pick.