When selecting a health insurance company, people usually look for figures such as the HDFC Ergo General Insurance Company’s claim settlement ratio. However, reliability is not solely about numbers. Medical emergencies are unpredictable and can be costly, so being able to rely on an insurer during such times matters greatly. A good claims settlement record can be one of the make-or-break factors when you need a health insurance policy.
In this article, we'll examine HDFC Ergo General Insurance Company’s claim settlement ratio in more detail, dissecting product features and benefits and where it stands within the industry. Whether you're shopping for coverage or comparing various insurers, knowing how the insurance company settles claims can assist you in making a better decision regarding your finances for covering medical expenses.
What Is The Claim Settlement Ratio And How Is It Calculated?
The health insurance claim settlement ratio is a key metric that indicates the percentage of insurance claims successfully resolved by an insurer relative to the total number of claims filed within a given financial year. With the use of the following formula, the calculation is simple:
Claim Settlement Ratio = (Number of claims settled) / (Total claims received + Outstanding claims at the beginning of the year) x 100 is the claim settlement ratio.
Although a high claim settlement ratio is often seen as an indicator of reliability, it doesn't offer a full picture. While it can provide some reassurance, other factors also influence how claims are processed.
Next, we'll examine HDFC Ergo General Insurance Company's claim settlement ratio in greater detail, as well as other important elements that can help you make an informed choice.
HDFC Ergo General Insurance Company’s Key Features and Benefits
In 2002, ERGO International AG and HDFC Ltd. formed ERGO General Insurance Company Limited as a joint venture. The organisation is headquartered in Mumbai, Maharashtra, and has an extensive list of insurance products available. The range of offerings includes individual insurance plans such as motor, health, travel, home, personal accident, etc, as well as business insurance options like property, marine, liability, and other insurance plans.
HDFC ERGO General Insurance Company has established a solid reputation in the insurance industry under the direction of CEO Mr Ritesh Kumar. We will examine some of the company's salient features below:
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% of Complaints Received On Overall Claims
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% of Complaints Received For After-Sales Service
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Claims Settled In Less Than 30 Days
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No. of Cashless Hospitals
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Source: HDFC ERGO General Insurance Company’s official website and public disclosures for the financial year 2023-2024.
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HDFC Ergo General Insurance Company’s Health Insurance Product Benefits:
Health insurance provides a money buffer when you have unforeseen medical bills to pay. The primary benefit? It keeps a significant portion of healthcare expenses covered, so you do not need to withdraw from your savings. From hospitalisation to medical treatment, it handles numerous costs and provides benefits such as:
- Covers Inpatient Hospitalisation Expenses
If you're hospitalised to receive treatment, your health insurance comes to your rescue to pay the bills. Most coverages have the condition of spending at least 24 consecutive hours in the hospital to be covered as an inpatient. Having fulfilled that criterion, the insurance pays for the expenses, such as the room rent, physician's charges, diagnostic tests, surgeries, and other ancillary hospital bills, so you can concentrate on getting well rather than depleting your savings.
- Covers Pre- and Post-Hospitalisation Costs
Health insurance not only pays for hospital expenses; it also pays for medical expenses prior to and subsequent to hospitalisation for a specified number of days. Pre-hospitalisation charges, such as diagnostic tests and consultations, are reimbursed if they're directly connected with the reason for hospitalisation and come under inpatient treatment. The same applies to post-hospitalisation expenses, for example, follow-up appointments, medicines, and diagnostic tests, provided they are connected to the same treatment and are within the terms of the policy.
- Covers Daycare Treatments
With advances in medical technology, most procedures do not require an overnight stay at the hospital. Daycare procedures like gallbladder surgery, hernia surgery, chemotherapy, etc., are covered by the insurance policy, and the bill is directly settled by the insurer.
- Includes Domiciliary Treatments
Domiciliary treatment is when the patient requires medical treatment to be done at home. It may be because of the nature of their condition or an insufficient number of available hospital beds. Under these circumstances, most health insurance plans intervene to cater for domiciliary treatment costs, such that vital medical attention is given promptly, even within the home environment.
- Offers Preventive Health Check-ups
Health insurance isn't all about covering expenses for emergency medical care; it's also used to encourage preventive treatment. Several policies include regular check-ups to assess health and identify any problems before they could get serious. This proactive mindset encourages individuals to focus on their health by making routine screenings and tests a priority, enabling the early identification of possible health concerns.
- Offers No Claim Bonus
If you don't file any claims in a policy year, your insurer can reward you with a no claim bonus. This can either enhance your sum insured without any additional cost or lower your premium when you renew your policy. It's a wonderful encouragement to stay healthy while also increasing your coverage.
- Provides Tax Benefits
Medical expenses aren't the only thing that health insurance is about. It can also help you save on taxes. Premiums paid towards the policy are a tax-deductible expense under Section 80D of the Income Tax Act, provided all requirements are fulfilled. The deduction limit varies based on the insured person, with greater benefits offered if parents or senior citizens are covered in the policy.
- Allows Cashless Treatment
One of the greatest benefits of health insurance is the cashless facility. In case you take treatment at an empanelled hospital, you don't have to pay for it upfront, and the insurance company takes care of settling the bill directly with the hospital. This is a much simpler process, especially in case of emergencies when access to treatment within the shortest time possible is so important. Anything that is not covered under the policy will still have to be paid by you.
Health insurance is a vital tool in the management of medical bills. It pays for everything from hospitalisation to preventive check-ups, offers tax relief, and even lets you tailor coverage with add-ons. It is like a financial safety net that keeps you ready for surprise medical bills.
That being said, health insurance policies can differ across insurers, with variations in coverage, terms, and conditions. It’s important to thoroughly review the policy documents to fully understand the specific benefits and coverage offered by each plan. Also, tax benefits are subject to existing tax laws and can change in the future.
What Is The HDFC Ergo Claim Settlement Ratio?
The HDFC Ergo General Insurance Company’s claim settlement ratio as of March 2024 is 95.30%. (Source: Public Disclosure, FY-2023-24).
What Is The Claim Process For HDFC Ergo General Insurance Company?
HDFC Ergo General Insurance Company provides two options to lodge a claim:
Cashless Claim
If you get treated at a hospital that is in the insurer's network, you can go for a cashless claim. That means you won't need to pay the hospital charges in advance and the insurer will pay the covered amount directly to the hospital. You just need to select a network hospital, go through the claim procedure, and pay only for any uncovered expenses under your policy.
Cashless Claim Process
To make a cashless claim on HDFC Ergo General Insurance Company, just follow these guidelines:
- Start by verifying your eligibility to make a claim on your health insurance policy. Ensure that the insurer provides cashless services at the hospital you have selected.
- Double-check that the hospital you select is not on the excluded list of the providers so that no issues arise in the process.
- Review your health insurance policy to understand its terms, conditions, and limitations so you’re aware of any potential out-of-pocket expenses.
- Collect all the relevant documents to make your claim, such as the policy copy or cashless card, passport-size photo, PAN and Aadhaar, and patient identification documents.
- Submit your request for the claim. In case of emergency hospitalisation, you have to notify your insurer within 24 hours of hospitalisation. For scheduled hospitalisations, notify the insurer at least 3–4 days prior.
- Make sure you submit all necessary documents for pre-authorisation, including: the health card issued by the insurance company, KYC documents for the proposer (such as PAN card, Aadhar card, and passport-size photo), ID documents of the patient, KYC of the insured person, policy number, policyholder’s name, the insured person’s name and address, details of the illness/injury and required treatment/surgery, the attending medical practitioner’s name and address, proposed date of admission, and past medical history (both related and unrelated to the current condition), which, if different from the information provided during policy commencement, could result in claim denial.
- In case the pre-authorisation is delayed, be prepared to make an advance deposit at the hospital so that treatment is not interrupted.
- Ensure that the hospital's insurance department submits all necessary documentation to your insurer once your discharge date is confirmed.
- Keep communication with your insurer open. Be prompt in replying to their queries or requirements for additional documents to prevent any delay.
- When you get the final bill and discharge summary, take the time to review them carefully to see what expenses are covered by the insurance policy and what you need to pay.
- If something does not make sense or you have a problem, contact your insurance company for an explanation or speak with a financial advisor.
- Be prepared to pay for any charges not covered by your insurer before you are discharged from the hospital
- Maintain a copy of all receipts and documents pertaining to the hospital stay for your records.
- Follow up with your insurer routinely to ensure that your claim is processed in due time and for updates on any progress.
Reimbursement Claims
When you get treated in a hospital which is not part of your insurance company's network, you'll have to make the hospital and other medical expenditures out of your pocket. When you've already paid, you can fill out a reimbursement claim form with your insurance company. They will evaluate the claim and reimburse you for the same subject to the provisions and conditions included in your health insurance policy.
Reimbursement Claim Process
To submit a reimbursement claim, start by:
- Confirm that the hospital you’ve chosen is not on the list of excluded healthcare providers.
- Notify your insurance company within 24 hours of hospital admission.
- At discharge from the hospital, gather all original documents, such as receipts, invoices, discharge summaries, medical reports, MRI/X-ray films, prescriptions, and the completed claim form (part of which is to be filled out by the hospital), etc.
- Ask for a copy of the patient's case sheet or indoor case papers and an itemised bill from the hospital.
- Verify the patient's name, gender, and age correctly in all documents and rectify any errors immediately.
- Collect documents such as health card or policy copy, KYC of the proposer (including PAN card, Aadhar card, passport-size photo), bank statement with the bank name, account number, and IFSC code printed, or a bank passbook copy with the latest transaction page, or an original cancelled cheque with the policyholder’s name printed; ID proof of the patient; a duly filled and signed claim form; all documents, test reports, films, receipts, and medical prescriptions related to the treatment; original discharge summary from the hospital; and the IOL sticker and invoice from the hospital for claims related to implantation (e.g., knee replacement, cataract surgery), etc.
- Organise all these documents in a file and make copies for your personal records.
- Complete the claim form and send it in to your insurer along with all supporting documents.
- Get an acknowledgement from your insurer for all the original documents you have submitted.
- Keep in touch with your insurer once the claim is submitted to track its progress.
- Provide further documentation as soon as asked by your insurer.
- Carefully read the claim settlement summary, paying special attention to any deductions.
- Consult your insurance company or financial consultant if you are unclear or have any issues.
Documents Required For HDFC Ergo General Insurance Company’s Claims
It may appear a little difficult at first to file a health insurance claim with HDFC Ergo General Insurance Company, but it's actually rather simple if you have the necessary paperwork. The documents needed to file a health insurance claim with HDFC Ergo General Insurance Company can vary depending on the type of claim (cashless or reimbursement) and the insurer’s specific requirements. However, the standard documents usually required are:
For Cashless Claims:
- Health card issued by the insurance company.
- KYC documents of the policyholder (such as PAN card, Aadhaar card, recent passport-sized photograph, etc.).
- Identity proof of the patient (Aadhaar card, passport, or other identification proof).
- KYC information of the insured person.
- Policy number for verification.
- Policyholder's full name.
- Full name and address of the insured person making the claim.
- Details of the illness or injury and details of the treatment or surgery required.
- Contact details of the doctor attending to the patient.
- Proposed date of hospital admission.
- Medical history (both relevant and irrelevant to the present condition), which, if different from the disclosures made during policy commencement with the initial policy information, may result in claim denial.
For Reimbursement Claims:
- Copy of insurance policy or health card.
- KYC documents of the proposer, viz.:
- Aadhaar card
- PAN card
- Current passport-size photo
- Bank statement displaying the account number, name of the bank, and IFSC code, passbook containing the current transaction page, or cancelled cheque bearing the print of the name of the policyholder.
- Proof of identity of the patient.
- Duly filled and signed claim form.
- All the documents pertaining to the treatment, including test reports, medical prescriptions, diagnostic films, and receipts.
- Original discharge summary from the hospital.
- IOL (Intra-Ocular Lens) sticker and bill for claims related to implantation procedures, such as knee replacement, cataract surgery, etc.
How To Track Your HDFC Ergo Health Insurance Plan’s Claim Status?
Just click on this link to know how your HDFC Ergo Health Insurance Policy's claim is going. You can track the progress of your claim by giving your policy number, mobile number, or email ID.
You can also contact the customer support team of HDFC Ergo General Insurance Company at 022-6234-6234 if you wish to. They will guide you through the process if you wish to track the progress of your claim.
To Conclude
HDFC Ergo General Insurance Company has a 95.30% claim settlement ratio as of March 31, 2024. Provided that you have all the documents required with you, the process is easy, whether it's a cashless claim or reimbursement. With the ever-evolving landscape of health insurance, you can have peace of mind knowing that your family and you are safeguarded against unexpected medical bills when working with a reputable insurance provider.
FAQs
The HDFC Ergo General Insurance Company claim settlement ratio as of March 2024 is 95.30%. (Source: Public Disclosure FY-2023-24)
HDFC Ergo General Insurance Company has settled 95.31% of claims in less than 30 days in FY 2023-24. (Source: Public Disclosure FY-2023-24). Once all required documents are received, the company will process the claim and either approve or deny it within 15 to 30 days of notification. However, the processing time may vary depending on the type and complexity of the claim.
HDFC Ergo General Insurance Company requires different documents for cashless and reimbursement claims. For cashless claims, you'll typically need your insurance policy details, KYC documents, health card, medical history, etc. For reimbursement claims, you'll generally need a filled-out claim form, a cancelled cheque, hospital statements, discharge summaries, medical records, and a policy copy. Requirements may vary, so it's best to confirm with the insurer.
Subject to the policy T&Cs, there is often a waiting time before HDFC Ergo General Insurance Company covers pre-existing diseases. Depending on the insurance plan you have chosen, the waiting period can be up to three years. To fully understand the terms and conditions that relate to covering pre-existing diseases, it is imperative to review your insurance policy document carefully.
Even with a valid policy, it is not a promise that your claim will be honoured. Claims are denied if they are not compliant with the explicit terms and conditions of the policy. Rejections most often arise from exclusions under the policy, failure to fulfil the waiting period requirements, absence of significant documents, or improper adherence to the guidelines by the insurer.
It is easy to track the status of your claim with HDFC Ergo General Insurance Company. You can track it through their mobile application, website, or customer hotline. Alternatively, you can seek assistance by visiting a local branch. To keep you informed along the way, some insurers, such as HDFC Ergo General Insurance Company, also provide periodic email or SMS updates.
The claim settlement ratio is influenced by several factors, such as the number of received and settled claims, the claim process efficiency, documentation accuracy, and whether the claims are in conformity with the policy terms and conditions.
A high claim settlement ratio is a sign that an insurer is dependable when it comes to handling claims. But it doesn't necessarily mean that your claim will be approved. Every claim is evaluated on an individual basis according to the terms and conditions of the policy as well as the correctness of the documents submitted.
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