Health Insurance (Non-Life) Data Analysis Report

Transcription

1 Health Insurance (Non-Life) Data Analysis Report Insurance Information Bureau of India

2 Health Insurance (Non-Life) Data Analysis Report Introduction The Insurance Information Bureau has been collecting transaction level data on Health Insurance policies, members and claims from all non life insurance and standalone health insurance companies in India. The Health data is collected in 3 formats. 1. Policy Data 2. Members Data 3. Claims Data The data received from Insurers for the year has been analyzed and the following analyses are generated for the information use of all the stake holders. Data Source IIB collects Health Insurance data through offline mode (i.e. CDs submission on half yearly basis) and online mode (i.e. uploading on to the IIB-website on monthly basis). The online mode commenced from financial year The data submitted through online mode are subjected to certain validation checks to prevent transaction data with some inconsistencies from entering the IIB data base. (Going forward, health insurance data submitted through online mode only will be utilized by IIB for analysis and generation of reports.) It was observed that a few insurers data submitted through online mode did not meet the minimum acceptance criteria, but their data submitted offline did. Nevertheless in order not to delay the generation of Health Insurance Report of any further, it has been decided to proceed with Offline submitted data of public sector insurers and Online submitted data of private sector insurers. Deficiency in the data considered for analysis: While arriving at analysis of attributes, the data records with discrepancies in values of respective attributes, have been excluded and a corresponding number of records with discrepancies is shown in the respective tables. Given the large size of data, despite these deficiencies, the trends / conclusions arrived at can be sufficiently representative of the whole population. Qualifier Under the section Detailed Analysis the data records with amount of claims paid less than `1/- and greater than `20,00,000/- have been excluded so as not to the get the analyses distorted due to the presence of outliers in claim paid data field. o Only 39% out of total claims data set have valid diagnosis codes (ICD-10) which account for 10 lac claim records and ` 2,141 crore claim paid amount. o 56% of the total number of claims do not have pin codes of the hospital. 44% of total claim records only have correctly filled-in Pin codes which account for 11.3 lac claim records and ` 2,551 crore claim paid amount. o 41% of the total claim records are shared among top 11 states. o The gender is specified for 78% of total claims records. o 24% of total number of claims paid have incorrect information about age and/or gender of the claimants. o The claim frequency among Females for diagnosis type PREGNANCY and PERINATAL PERIOD CONDITIONS is observed to have non-zero values for age greater than 55 and also for age less than 16 which could be due to incorrect information in age or date of birth or diagnosis codes of claimants. o 15% in number accounting for 22% in claim paid amount did not have hospital stay information. Insurance Information Bureau of India Page 1

3 Health Insurance (Non-Life) Data Analysis Report Executive Summary: Number of Policies issued in increased by 6% whereas number of insured members and number of claims paid in the year have reduced by 45% and 33% respectively when compared with those of which could be attributable to data omissions/errors in member and claim data sets. In the year the Health Premium has increased by 0.09%. However, Total Claim Paid Amount has declined by 21% when compared with that of Claim paid ratio has declined by 21%, from 99% in to 78% in % increase in number of policies and 0.09% increase in premium has resulted in decrease in 'Premium per policy' by 6%, whereas 33% reduction in number of claims has resulted in 'Claim Paid Amount per policy' being decreased by 26%. Reduction in number of members by 45% has resulted in increase in Premium per insured member by 80% and Claim Paid Amount per insured member has increased by 42%. The number of persons insured per policy has decreased to 4. Gender-wise Claims Summary, compared to previous year (Chart 9 - Appendix: HR-4): o Percentage -wise number of claims in respect of males increased from 54% to 59%. o Percentage -wise claim paid amount in respect of males increased from 56% to 64%. o Average claim paid amount of males increased from ` 22,402/- to ` 27,490/- (23% increase). o Average claim paid amount of females increased from ` 20,279/- to ` 22,343/-(10% increase). Age-wise Claims Summary (Chart 10.a, 10.b- Appendix: HR-5): o Age-band of '46-55' is highest claim making group both in number and claim paid amount with 27% share in number and 25% in amount followed by '26-35' (14%/11%) and 'Less than 1 year' (12%/23%). o Age-bands '6-15' through '46-55' witness a smooth increase in number of claims. Thereafter a steep decrease of number of claims is observed. There is a slight dip in number of claims in age-band Thus number of claims for young children (starting from age 6 years) is low and increases with the increase in age up to the middle-age. o 82% in number and 78% in amount of claims are paid to aged up to 55. o 17% in number and 9% in amount of claims are paid to age up to 25. o Thus for youngsters below 25, the percentage of number of claims paid is high but that of claims paid amount is low. Most of the claims are paid to individuals aged below 55. o Abnormally high levels of claims both number-wise and amount-wise are paid to members with age-band 'Less than 1 year'. 12% in number of claims which accounted for 23% in amount are from age-band 'Less than 1 year'. This could be attributable to incorrect information in 'age' or 'date of birth' data fields of members where possibly 0 is filled in. o Average claim paid amount gradually increases from age-band '1-5' to that 'Above 70'. The lowest average claim paid amount is ` 12,417/- for age-band '1-5 years' and highest average claim paid amount is ` 40,684/- for age-band 'Above 70 years'. o Thus, on an average, the higher the age-band the higher the average amount of claim paid. Health Insurance Policies- Individual Cover (Chart 11.a, 11.b- Appendix: HR-5.1): o The ratio of number of claims paid to number of members insured is highest for age-band Less-than 1 year (49%), second highest for age-band 'Above 70' years (27%) and is lowest for age-band 6-15 years (3%). The ratio consistently increases throughout all the age-bands starting from o The average amount of claim paid is highest for the age-band Above 70 (` 42,479) and lowest for age-band 1-5 years (` 11,155/-). It consistently increases throughout all the age-bands starting from 1-5. o Thus both ratio of number of claims paid to number of members insured and "average amount of claim paid" increase with the age. o The numbers of members insured are highest in age-bands (35.8 lacs) and (35.7 lacs) and lowest in age-band Less than 1 year (94,162). o 89% of members insured are aged 55 and below. o Average sum insured per member is highest for age-band (` 2,06,454/-) and lowest for age-band Less-than 1 year (` 70,447/-). The average sum insured per member increases from age-band Less-than 1 year till and thereafter decreases gradually in higher age-bands. o For age greater than 60 years the average claim paid amount keeps increasing and the average sum insured keeps falling (Chart 11a, 11b- Appendix: HR-5.1). o The sum insured utilization i.e., average claim paid per average sum insured (%) is highest for age-band Above 70' years (25%) and lowest for age-band 1-5 years (12%). It increases consistently from age-band years. The sum insured utilization seems to be elevated for age-bands 6-15 (17%) and (17%) in comparison to the Insurance Information Bureau of India Page 2

4 Health Insurance (Non-Life) Data Analysis Report o neighbouring age-bands 1-5 (12%) and (15%). Thus, the average sum insured of the age-bands 6-15 (` 91,151/-) and (` 1,15,391/-) is lower than that of age-band years (` 1,45,998/-) but proportion of average claims paid amount out of average sum insured is higher for age-bands 6-15 (17%) and (17%) as compared to (15%), indicating that age-bands 6-15 and consume more proportion of their sum insured for hospitalization costs as compared to age-band years (Chart 11b- Appendix: HR-5.1). Though, it is observed that age-band Less-than 1 year shows high levels of ratio of number of claims paid to number of members insured and "average claim paid per average sum insured" this apparent anomaly could be due to incorrect information in 'age' or 'date of birth' fields of members where possibly 0 is filled in. Age and Gender-wise Claims Summary (Chart 12- Appendix: HR-6): o Number of claims of males is more than that of females for all age-bands except for the age-bands '16-25' and '26-35' where they are less by 1% and 2% respectively. o Age-band Less-than 1 year shows high number of claims paid as well as an abnormal ratio between male and female. This anomaly could be due to incorrect information in age or date of birth of members where possibly 0 is filled in. o Irrespective of gender, the average amount of claim paid is highest for the age-band Above 70 and lowest for ageband 1-5 years. It consistently increases throughout all the age-bands starting from 1-5. o Average amount of claim paid per male claimant is more than that of female across all age bands. Types of Cover-wise Claims Summary (Chart 13- Appendix: HR-7): o Individual and Individual floaters account for 90 % of number of polices but only 44 % of amount of premiums. o With a meagre share of 3% in number of health insurance policies, group type of policy (Group + Group floater) commands 56% of the total health insurance industry premium. o The individual floater policies alone account for 22% of total number of policies and 22% of total policy premium within the range of (individual + individual floater) type policy covers. Whereas the group floater policies alone account for 84% of total number of policies and 81% of total policy premium within the range of (group + group floater) type policy covers. o Thus group-floaters are more prevalent than group policies and individual policies are more prevalent than individual-floater policies. Disease-wise Claims Summary (Chart 14- Appendix: HR-8): o The top six highest number of claims paid categories are from disease groups 'INFECTIOUS', 'CLINICAL FINDINGS', 'UROLOGY', 'DIGESTIVE', 'PREGNANCY' and 'INJURY', in that order which account for 64% in number and 53% in claim paid amount. o The average claim paid amount is highest for CIRCULATORY, MALFORMATIONS/DEFORMATIONS, ARTHROPATHIES, NEOPLASM and INJURY, in that order. State-wise Claims Summary basing on Hospital Pincode(Chart 15- Appendix: HR-9): o Like in previous years, Maharashtra leads the states with 22% share in total claims records (excluding claim records where Hospital Pincodes are not available). Gujarat (12%), Tamilnadu (10%) continue to be in top 5 positions for the 5th year in succession. o Top six States in terms of number of claims paid, 'MAHARASHTRA', 'GUJARAT', 'WEST BENGAL', 'TAMIL NADU', 'DELHI' and 'KARNATAKA' account for 72% in number and 76% in claim paid amount. o The States, having less than 10,000 claims records each are, 'ORISSA', 'ASSAM', 'GOA', 'BIHAR', 'TRIPURA', 'UTTARAKHAND', 'CHATTISGARH', 'CHANDIGARH' and 'PONDICHERRY'. o Considering only those with > 10,000 claim records, the top six states of Hospitalization for which average claim paid amount is high are 'DELHI', 'MAHARASHTRA', 'ANDHRA PRADESH', 'HARYANA', 'UTTAR PRADESH' and 'RAJASTHAN', in that order. o Further classifying States into Northern, Eastern, Central, Western, Sothern and Union Territories regions, following is observed: REGIONS IN INDIA PROPORTION OF NUMBER OF CLAIMS PAID PROPORTION OF AMOUNT OF CLAIMS PAID WEST INDIA 36% 39% SOUTH INDIA 28% 26% EAST INDIA 13% 10% NORTH INDIA 10% 11% UNION TERRITORIES 9% 13% CENTRAL INDIA 3% 2% Insurance Information Bureau of India Page 3

5 Health Insurance (Non-Life) Data Analysis Report Thus Western India contributes to highest number of claims and claim paid amount, followed by Southern India. Central India contributes least number of claims and claim paid amount. Union Territories (where major contributor is DELHI) contribute 'number of claim paid' at second lowest level but contribute 'amount of claims paid' at third highest level, compared to other regions of India. Claim Paid Band-wise Distribution of Claims (Chart 16- Appendix: HR-10): o 99% of 'total number of claims paid' are below the amount of `3 lakhs which account for 73% share in 'total amount of claims paid'. o Maximum number of claims paid falls in the claim paid band of ` `25000 (29%) followed by ` ` (17%). o The claims with paid amounts less than ` 1,000 account for 13% share in 'total number of claims paid' statistic but contributes only 0.12% to ' total amount of claims paid' statistic. Thus the transaction level data has considerable number of claim records corresponding to negligible amount of claims paid. o The claim paid band 'Above ` 20,00,000' accounts only for 0.07% share in 'total number of claims paid' statistic but contributes 15% to 'total amount of claims paid' statistic. Thus the transaction level data has negligible number of claim records resulting in extreme values of claims paid amount. Age-Gender-Type of Policy wise Proportion of Claims (Chart 17- Appendix: HR-11): o The proportion of total number of claims paid from Individual policies is 59% and that from the group policies is 41%. o Out of the claimants holding individual policies, the males' proportion exceeds that of females by 19%. o Out of the claimants holding group policies the males' proportion exceeds that of females by 12%. o Claimants with Individual Policy: o Highest number of claimant members (both gender) belong to age-band '36-45' and lowest in the age-band 'Less-Than 1 year'. o Irrespective of gender, there is consistent increase in proportion of claims paid upto age-band '36-45' years and thereafter it decreases steadily. o Claims of females in the age-range years outnumber those of males. o Claimants with Group Policy: o o o Male proportion in age 'Less than 1 year' is unusually high which could be due to incorrect information in 'age' or 'date of birth' data fields of members where possibly 0 is filled in. Therefore age 'Less than 1 year' is not considered for further analysis. The highest claiming members (both gender) belong to age-band '26-35'. The proportion of females claims in the age-range '16-60' is more than that of males. The female proportion in age-bands '16-25' and '26-35' is quite high compared to that of males which could be due to the Pregnancy cover being utilized by female members. Age and Disease-wise Claim frequency of MALES {No. of claims / No. of Members Insured} (Appendix: HR-12.1): o The claim frequency for Males with age 'Less than 1 year' is unusually high and is also greater than 100% which could be due to incorrect information in 'age' or 'date of birth' data fields of claimants where possibly 0 is filled in. Therefore age 'Less than 1 year' is not considered for further analysis. o Claims frequency increases consistently from age-band 26-35' (4%) till Above 70 Years (26%). Thus as the age of Male members increases the susceptibility to claim, out of hospitalization, also increases. o Overall, Males' claim frequency (i.e. number of claims out of total members insured) is 6.704%. o Considering only those claims where disease codes are available, the top six diseases with highest claim frequency for Males are INFECTIOUS (0.534%), CLINICAL FINDINGS (0.33%), DIGESTIVE (0.288%), INJURY (0.271%), UROLOGY(0.256%) and CIRCULATORY (0.222%). o Within each of the above six diseases, the following top three age-bands of MALES have highest claim frequency: TOP SIX DISEASES HIGHEST CLAIM SECOND HIGHEST CLAIM THIRD HIGHEST CLAIM FREQUENCY & AGE BAND FREQUENCY & AGE BAND FREQUENCY & AGE BAND INFECTIOUS 1-5 years (0.915%) 6-15 years (0.704%) years (0.522%) CLINICAL FINDINGS Above 70 years (0.762%) 1-5 years (0.758%) years (0.507%) DIGESTIVE years (0.574%) Above 70 years (0.544%) years (0.481%) INJURY Above 70 years (0.335%) years (0.33%) years (0.308%) UROLOGY years (0.993%) Above 70 years (0.827%) years (0.767%) CIRCULATORY years (1.91%) Above 70 years (1.219%) years (0.925%) Insurance Information Bureau of India Page 4

6 Health Insurance (Non-Life) Data Analysis Report Age and Disease-wise Claim frequency of FEMALES {No. of claims / No. of Members Insured} (Appendix: HR-12.2): o Claim frequency increases consistently from age-band '6-15 years' (4%) till Above 70 Years (22%) with a slight dip in claim frequency in the age-band '36-45 years'. Thus as the age of Female members increases the propensity to claim, out of hospitalization, also increases. o Overall, Females' claim frequency (i.e. number of claims out of total members insured) is 7.284% which is higher than that of Males. o In the age-bands '1-5 years' and '16 to 65 years' Females' claim frequency is more than that of Males. o The Claim frequency of Females exceeds that of Males for all diseases except INJURY, CIRCULATORY, ACCIDENT and MENTAL DISORDERS. o Considering only those claims where disease codes are available, the top six diseases with highest claim frequency for Females are PREGNANCY (0.726%), INFECTIOUS (0.685%), CLINICAL FINDINGS (0.437%), UROLOGY(0.404%), DIGESTIVE (0.354%) and EYE (0.241%). o Within each of the above six diseases, the following top three age-bands of FEMALES have highest claim frequency: TOP SIX DISEASES HIGHEST CLAIM FREQUENCY & AGE BAND SECOND HIGHEST CLAIM FREQUENCY & AGE BAND THIRD HIGHEST CLAIM FREQUENCY & AGE BAND PREGNANCY years (1.946 %) years (1.357 %) years (0.166 %) INFECTIOUS Above 1-5 years (0.937%) years (0.786%) years (0.719%) CLINICAL 1-5 years (0.814%) Above 70 years (0.642%) years (0.546%) FINDINGS UROLOGY years (0.803 %) years (0.777%) years (0.586%) DIGESTIVE years (0.475%) years (0.46%) years (0.418%) EYE years (1.726%) years (1.42%) Above 70 years (1.315%) Claim Paid Band (in `) and Disease-wise Proportion of Number of Claims Paid (in %) (Appendix: HR-13.1, 13.2): o Proportion of Number of Claims across Disease type and Claim Paid Band = No of Claims (for each type of disease in each Claim paid band) divided by Total Number of Claims (for all diseases). o Maximum number of claims paid are of amount below ` 75,000. o The claim-paid bands ' ` `25000 '(28.56%), ' ` ` '(16.90%), ' ` `10000 ' (15.40%), ' ` `5000 '(15.04%), ' `1 - `500 ' (9.59%)and ' ` `75000' (4.54%) (containing highest proportion of claims paid, in that order) account for 90% of total number of claims paid. o Within each of the above six claim-paid bands, the following top three diseases account for highest proportion of claims: TOP SIX CLAIM-PAID BANDS ` `25000 ` ` ` `10000 ` `5000 `1 - `500 ` `75000 HIGHEST CLAIM PROPORTION & DISEASE INFECTIOUS (1.77 %) PREGNANCY (1.29 %) INFECTIOUS (1.36 %) INFECTIOUS (1.06 %) INFECTIOUS (1.98%) INJURY (0.23%) SECOND HIGHEST CLAIM PROPORTION & DISEASE PREGNANCY (1.17 %) DIGESTIVE (0.67 %) CLINICAL FINDINGS (0.64 %) CLINICAL FINDINGS (1.06 %) CLINICAL FINDINGS (1.11%) DIGESTIVE (0.22%) THIRD HIGHEST CLAIM PROPORTION & DISEASE EYE (1.11 %) UROLOGY (0.59 %) DIGESTIVE (0.61 %) UROLOGY (0.58 %) UROLOGY (0.42%) UROLOGY (0.19%) Claim Paid Band (in `) and Disease-wise Proportion of Amount of Claims Paid (in %) (Appendix: HR-13.3, 13.4): o Proportion of Amount of Claims Paid (in %) across Disease type and Claim Paid Band = Amount of Claims Paid (for each type of disease in each Claim paid band) divided by Total Amount of Claims (for all diseases). o Maximum proportions of claim paid are from claim paid bands ` ` (23.19%), ` `50000 (21.36%), ` `25000 (21.36%), ` `75000 (9.89%) and ` ` (7.46%), in that order. Thus 79% of total amount of claims paid belongs to range `10,000-`3,00,000. Insurance Information Bureau of India Page 5

7 Health Insurance (Non-Life) Data Analysis Report o The top six highest proportions of amount of claims paid are from disease group CIRCULATORY, INJURY, DIGESTIVE, INFECTIOUS, PREGNANCY, UROLOGY, in that order. These diseases account for 62% of total amount of claims paid (where total claim paid amount is considered after ignoring the missing/incorrect diagnosis codes). Disease-wise and Days of Hospitalization-wise Proportion of Claims Paid (Appendix: HR-14.1, 14.2): o Lengths of stay 'Less than 1 day' and '3 days' had considerable chunks both in number and paid amounts of claims. o 23% in number accounting for 15% in claim paid amount were paid for hospital stay 'Less than 1' day. o 18% in number accounting for 16% in claim paid amount were paid for hospital stay '3 days'. o 54% in number accounting for 40% in claim paid amount were paid for hospital stay '0-3' days. o 67% in number accounting for 55% in claim paid amount were paid for hospital stay '0-10' days. o 18% in number accounting for 23% in claim paid amount were paid for hospital stay beyond 10 days. TPAs Vs Insurer's In-house Claims Settlements(Chart 4- Appendix: HR-15): o Distribution of number of claims between TPA and Insurers' In-house settlement is 46% and 54% respectively showing a possible tendency among insurers to have more control over claim settlement. Correspondingly the claim paid amount % between TPAs and In-house is 42% and 58% respectively. o Average claim paid by TPAs is less than that of In-house settlement by 17%. Product Type-wise Premium and Claim Summary (Chart 5, 6- Appendix: HR-16, HR-17): o Health insurance market is dominated by Hospitalization Indemnity Products which account for 86.8% of total Health Insurance Premium and 89.6% of total amount of Health Insurance claims paid. o Package policy premium accounts for 6.2% of total Health Insurance Premium and 8.1% of total amount of Health Insurance claims paid. o Hospital Cash Plan accounts for 3.7% of total Health Insurance Premium and 1.6% total amount of Health Insurance claims paid. Age- wise Claims Summary- Package Policy (Chart 7- Appendix: HR-20): o Age band '26-35' is the highest claim prone one with 27% in number and 29% in amount of claim paid under Package policy. Distant second positions are held by age band '36-45' in number and '46-55' in amount paid. o 67% in number and 65% in amount claimed by age range 16 to 55 years. After age 55 gradual decline in number and amount paid is visible. Metro City -wise Claims Summary (Chart 8- Appendix: HR-21): Among six metro cities Delhi, Mumbai, Kolkata, Chennai, Bangalore and Hyderabad, Delhi leads them in number of claims while Mumbai leads them in total amount of claims paid and average claim paid amount. Bangalore has the least average claim paid amount. Insurance Information Bureau of India Page 6

8 Numbers of Policies and Claims Number of Members Health Insurance (Non-Life) Data Analysis Report MACRO INDICATORS Macro Indicators on (Non-Life) Health Insurance Data HR-1: Policies, Insured Members and Claims Year Number of Policies Number of Members Number of Claims * 22,65,451 83,61,629 3,60, * 20,59,449 89,87,239 5,55, * 38,28,495 1,63,45,575 10,16, * 31,10,475 1,79,07,430 10,60, * 37,90,838 2,41,21,625 14,36, * 45,75,725 3,27,10,604 20,81, ** 68,84,687 5,48,93,453 32,63, ** 77,42,076 5,25,08,111 38,43, *** 82,25,112 2,91,34,940 25,91,781 # NB: 1. * Policies serviced by TPAs only. 2. ** Figures of Policies serviced by TPAs and directly serviced by Insurers 3. *** Data submitted online by PVT insurers and offline by PSU insurers. 4. # - Inclusive of Claim Records where Claim Paid Amount >`20 lakh Chart 1, Table HR-1 Number of Policy, Insured Members and Claims by Years 9,000,000 60,000,000 8,000,000 7,000,000 50,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000, ,000,000 30,000,000 20,000,000 10,000, Years Number of Claims Number of Members Number of Policies # - Inclusive of Claim Records where Claim Paid Amount >`20 lakh Inference: Number of Policies issued in have increased by 6% whereas number of insured members and number of claims paid in the year have reduced by 45% and 33% respectively when compared with those of which could be attributable to data omissions/errors in member and claim data sets. Insurance Information Bureau of India Page 7

9 Amount ( ` in Crs.) Claim Paid Ratio (in %) Health Insurance (Non-Life) Data Analysis Report HR-2: Total Premium, Total Claim Paid and Claim Ratio Period Premium (` in Crs.) Claims paid (` in Crs.) Claims Paid Ratio (in %) * % * % * 1,947 1,777 91% * 2,820 2,198 78% * 2,758 2, % * 3,976 4, % ** 7,803 7,456 96% ** 10,932 10,797 99% *** 10,942 8,499 # 78% NB: 1. * Policies serviced by TPAs only. 2. ** Figures of Policies serviced by TPAs and directly serviced by Insurers 3. *** Data submitted online by PVT insurers and offline by PSU insurers. 4. # - Inclusive of Claim Records where Claim Paid Amount > `20 lakh 5. Claim Paid Ratio = Total Claim Paid Amount / Total Premium * 100 Chart 2, Table HR-2 12,000 11,000 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 - Total Premium, Claim Paid Amount and Claim Paid Ratio by Years Years Premium Claims Paid Amount Claims Paid Ratio (in %) 120% 100% 80% 60% 40% 20% 0% # - Inclusive of Claim Records where Claim Paid Amount >`20 lakh Inference: In the year the Policy Premium has increased by 0.09%. However, Total Claim Paid Amount has declined by 21% when compared with that of Claim paid ratio has declined by 21%, from 99% in to 78% in Insurance Information Bureau of India Page 8

10 Health Insurance (Non-Life) Data Analysis Report HR-3: Average Premium, Average Claim Paid and Average Persons Insured - Per Policy and Per Member Year Premium per Policy (in `) Premium per Insured Member (in `) Number of Persons Insured Per Policy Claim Paid per Policy (in `) Claim paid per Insured Member (in `) * 4,166 1, , * 4,792 1, ,606 1, * 4,892 1, ,642 1, * 9,067 1, ,066 1, * 7,275 1, ,661 1, * 8,689 1, ,932 1, ** 11,333 1, ,910 1, ** 14,120 2, ,946 2, *** 13,303 3, ,333 # 2,917 # NB: 1. * Policies serviced by TPAs only. 2. ** Figures of Policies serviced by TPAs and directly serviced by Insurers 3. *** Data submitted online by PVT insurers and offline by PSU insurers. 4. # - Inclusive of Claim Records where Claim Paid Amount > `20 lakh Chart 3, Table HR-3 Average Premium and Claim Paid Amount Per Member (in `) Average Premium and Claim Paid Amount by Years Years 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Average Premium and Claim Paid Amount Per Policy (in `) Claim paid per Insured Member Premium per member Premium per Policy Claim Paid per Policy # - Inclusive of Claim Records where Claim Paid Amount >`20 lakh Inference: The values expressed in table HR-3 are derived from tables HR-1 and HR-2. When comparing the figures with that of the following are observed that: 6% increase in number of policies and 0.09% increase in premium has resulted in decrease in 'Premium per policy' by 6%, whereas 33% reduction in number of claims has resulted in 'Claim Paid Amount per policy' being decreased by 26%. Reduction in number of members by 45% has resulted in increase in Premium per insured member by 80% and Claim Paid Amount per insured member has increased by 42%. The number of persons insured per policy has decreased to 4. Insurance Information Bureau of India Page 9

11 Health Insurance (Non-Life) Data Analysis Report DETAILED ANALYSES [For detailed data, please refer to HR tables in the Appendices] TPA Vs. Insurers' In-house Claim Settlement Chart 4- Appendix: HR-15 Average Claim Paid Amount(in `) TPA vs In-House Number of Claims Paid TPA vs In-House Claim Paid Amount(in ` Cr) TPA vs In-House 25,345 1,204,173, 46% 3,052.03, 42% 30,368 TPA Inhouse 1,385,844, 54% TPA Inhouse 4,208.46, 58% TPA Inhouse # - Excluding claim records where Claim Paid amount >`20 lakh Inference: Distribution of number of claims between TPA and Insurers' In-house settlement is 46% and 54% respectively showing a tendency among insurers to have more control over claim settlement. Correspondingly, the claim paid amount % between TPAs and In-house is 42% and 58% respectively Average claim paid by TPAs is less than that of In-house settlement by 17%. Product Type-wise Premium and Claims Summary Chart 5- Appendix: HR-16 Share in Amount of Claims Paid Type of Product Share in Number of Claims Type of Product 0.27% 0.30% 0.08% 8.15% 1.60% 0.00% 12.22% 1.93% 0.52% 0.23% 0.01% 0.00% 89.61% 85.10% Hospitalisation Indemnity Policy Package Policy Hospital Cash Plan Any Other Product Hybrid Policy Critical Illness Cover - Benefits Critical Illness Cover - Indemnity # - Excluding claim records where Claim Paid amount >`20 lakh Hospitalisation Indemnity Policy Hospital Cash Plan Hybrid Policy Critical Illness Cover - Indemnity Package Policy Any Other Product Critical Illness Cover - Benefits Insurance Information Bureau of India Page 10

12 Claim Paid Amount (` in crs.) Number of Claims Health Insurance (Non-Life) Data Analysis Report Chart 6- Appendix: HR-17 Share in Amount of Premium Type of Product 6.19% 3.56% 0.38% 2.80% 0.18% 0.00% 0.02% Share in Number of Policies Type of Product 0.98% 1.31% 7.08% 2.68% 2.23% 0.01% 0.01% 86.87% 85.72% Hospitalisation Indemnity Policy Package Policy Hospital Cash Plan Any Other Product Hybrid Policy Critical Illness Cover - Benefits Critical Illness Cover - Indemnity Declaration Policy # - Excluding claim records where Claim Paid amount >`20 lakh Hospitalisation Indemnity Policy Hospital Cash Plan Hybrid Policy Critical Illness Cover - Indemnity Package Policy Any Other Product Critical Illness Cover - Benefits Declaration Policy Inference: Health insurance market is dominated by Hospitalization Indemnity Products which accounts for 86.9% of total Health Insurance Premium and 89.6% of total amount of Health Insurance claims paid. Package policy premium accounts for 6.2% of total Health Insurance Premium and 8.1% of total amount of Health Insurance claims paid. Hospital Cash Plan accounts for 3.7% of total Health Insurance Premium and 1.6% total amount of Health Insurance claims paid. Age-wise Claims Summary - Package Policy Chart 7- Appendix: HR-20 Age-band-wise Number of Claims and Amount of Claims Paid Package Policy Above 70 Age-Band (in years.) 100,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 - Total Claims Paid (` in crs.) Number of Claims # - Excluding claim records where Claim Paid amount >`20 lakh Inference: Age band '26-35' is the highest claim prone one with 27% in number and 29% in amount of claims paid under Package Policy. Distant second positions are held by age band '36-45' in number and '46-55' in amount paid. 67% in number and 65% in amount claimed by age range 16 to 55 years. After age 55, gradual decline in number and amount paid is visible. Insurance Information Bureau of India Page 11

13 Amount of Claims Paid (` in Crs.) Number of Claims Paid Health Insurance (Non-Life) Data Analysis Report Metro City-wise Claims Summary Amount of Claim Paid (in ` crs) ,556 33,825 Chart 8- Appendix: HR-21 Metro City-wise Claims Summary 25,657 28,303 27,889 28,613 DELHI MUMBAI BANGALORE KOLKATA CHENNAI HYDERABAD Metro Cities Total Claims Paid Amount (in ` Crs) Number of Claims Paid Average Claim Paid Amount (in `) 120, ,000 80,000 60,000 40,000 20,000 0 Number of Claims Paid Average Claim Paid (`) # - Excluding claim records where Claim Paid amount >`20 lakh Inference: Among six metro cities Delhi, Mumbai, Kolkata, Channai, Bangalore and Hyderabad, Delhi leads them in number of claims, while Mumbai leads them in amount of claims paid and average claim paid amount. Bangalore has least average claim paid amount. Gender-wise Claims Summary Chart 9- Appendix: HR-4 Gender-wise Number and Amount of Claims Paid ,500 3,000 2,500 2,000 1,500 1, Male Female Gender Not Specified Gender Claims Paid Amount ( ` in Crs.) Number of Claims Paid 1,400,000 1,200,000 1,000, , , , ,000 - # - Excluding claim records where Claim Paid amount >`20 lakh Inference: 22% of claim records do not have Gender information. Considering only those claim records where gender is specified the following is observed: For the year , out of total number of claims paid, number of claims paid to males increased from 54% to 59%. Thus in the year , claim experience(would incidence be more appropriate?)of Males has increased and that of Females has decreased by 5%. For the year , out of total amount of claims paid, amount of claims paid to males increased from 56% to 64%. Thus in the year , amount of claims paid to Males has increased and that to Females has decreased by 8%. Compared to previous year, the average claim paid amount to Males increased from ` 22,402/- to ` 27,490/- (23% increase) and that to Females increased from ` 20,279/- to ` 22,343/-(10% increase). The gap between the average claim paid amount of Males and Females has increased from ` 2,123/- ( ) to `5,147/- ( ). Insurance Information Bureau of India Page 12

14 Average Claim Paid Amount (in `) Number of Claims Paid Amount of Claims Paid (` in Crs.) Number of Claims Paid Health Insurance (Non-Life) Data Analysis Report Age-wise Claims Summary Chart 10.a- Appendix: HR-5 Age-wise Number and Total Amount of Claims Paid , , , , , , Less than Above 70 Age-Band (in Years) Total Claim Paid Amount (` in Crs.) Number of Claims Paid 800, , , , , , , ,000 - # - Excluding claim records where Claim Paid amount >`20 lakh Chart 10.b- Appendix: HR-5 60,000 50,000 40,000 30,000 20,000 10,000 Age-wise Number of Claims Paid and Average Claim Paid Amount ,361 40,684 35,261 35,546 31,920 26,678 23,176 21,102 17,637 12,417 12, , , , , , , , ,000 - Less than 1 # - Excluding claim records where Claim Paid amount >`20 lakh Above 70 Age-Band (in Years) Number of Claims Paid Average Claim Paid (in `) Average Claim Paid (`) Inference: Abnormally high levels of claims both number-wise and amount-wise are paid to members with age-band 'Less than 1 year'. 12% in number of claims which accounted for 23% in amount are from age-band 'Less than 1 year'. This could be attributable to incorrect information in 'age' or 'date of birth' data fields of members where possibly 0 is filled in. Age-band of '46-55' is highest claim prone group both in number and claim paid amount with 27% share in number and 25% in amount followed by '26-35' (14%/11%) and 'Less than 1 year' (12%/23%). Age-bands '6-15' through '46-55' witness a smooth increase in number of claims. Thereafter a steep decrease of number of claims is observed. There is a slight dip in number of claims in age-band Thus number of claims for young children (starting from age 6 years) is low and increases with the increase in age upto the middle-aged individuals. 82% in number and 78% in amount of claims are paid to aged up to % in number and 9% in amount of claims are paid to age up to 25. Thus for youngsters below 25, the percentage of number of claims paid is high but that of claims paid amount is low. Most of the claims are paid to individuals with age less than 55. Average claim paid amount gradually increases from age-band '1-5' to that 'Above 70'. The lowest average claim paid amount is ` 12,417/- for age-band '1-5 years' and highest average claim paid amount is ` 40,684/- for age-band 'Above 70 years'. Thus, on an average, the higher the age-band the higher the average amount of claim paid. - Insurance Information Bureau of India Page 13

15 Number of members insured (in tens) and Average Sum Insured (in `) Sum Insured Utilization (in %) Average Amount of Claims Paid (in `) Ratio of No. of Claim to No. of Members Health Insurance (Non-Life) Data Analysis Report Health Insurance Policy - Individual Cover Chart 11.a- Appendix: HR ,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 - Age-wise Average Claims Paid & Ratio of Number of Claims to Number of Members Insured Individual Policy % 13,024 6% 11,155 15,450 19,784 21,378 3% 4% 5% 25,464 6% 30,992 10% 34,822 35,862 13% 17% 37,414 21% 42,479 Less than Above 70 Age-Band (in Years) Average Amount of Claims Paid (in `) Ratio of Number of Claims to Number of Members Average Claim Paid (`) 27% 60% 50% 40% 30% 20% 10% 0% # - Excluding claim records where Claim Paid amount >`20 lakh Chart 11.b- Appendix: HR Age-wise Average Sum Insured per Member, Sum Insured Utilization Individual Policy % % 12% 17% 17% 15% 15% 17% 17% 18% 21% 25% 25% 20% 15% % 5% 0 Less than Above 70 Age-Band (in Years) Number of Members Insured (in tens) Average Sum Insured per Member ( in ` ) Sum Insured Utilization (%) = Avg. Amount of Claims Paid / Avg. Sum Insured per Member # - Excluding claim records where Claim Paid amount >`20 lakh Sum Insured Utilization(%) 0% Inference: Considering the Health Insurance Policies issued to Individuals, following observations are made in respect of members insured, sum insured and claims paid: The ratio of number of claims paid to number of members insured is highest for age-band Less-than 1 year (49%), second highest for age-band 'Above 70' years (27%) and is lowest for age-band 6-15 years (3%). The ratio consistently increases throughout all the age-bands starting from The average amount of claim paid ( i.e. total claim paid amount total number of claims paid) is highest for the age-band Above 70 (` 42,479 and lowest for age-band 1-5 years (` 11,155/-). It consistently increases throughout all the agebands starting from 1-5. Thus both ratio of number of claims paid to number of members insured and "average amount of claims paid" increase as we move up the age bands. Insurance Information Bureau of India Page 14

16 Health Insurance (Non-Life) Data Analysis Report The numbers of members insured are highest in age-bands (35.8 lacs) and (35.7 lacs) and lowest in ageband Less than 1 year (94,162). 89% of members insured are aged 55 and below. Average sum insured per member is highest for age-band (` 2,06,454/-) and lowest for age-band Less-than 1 year (` 70,447/-). The average sum insured per member increases from age-band Less-than 1 year till and thereafter decreases gradually in higher age-bands. For age greater than 60 years the average claim paid amount keeps increasing and the average sum insured keeps falling. The sum insured utilization i.e., average claim paid per average sum insured is highest for age-band Above 70' years (25%) and lowest for age-band 1-5 years (12%). It increases consistently starting from age-band years. Thus, for members with age greater than 25, as the age increases more proportion of sum insured is consumed for hospitalization costs. The sum insured utilization seems to be elevated for age-bands 6-15 (17%) and (17%) in comparison to the neighbouring age-bands 1-5 (12%) and (15%). Thus, the average sum insured of the age-bands 6-15 (` 91,151/-) and (` 1,15,391/-) is lower than that of age-band years (` 1,45,998/-) but proportion of average claims paid amount out of average sum insured is higher for age-bands 6-15 (17%) and (17%) as compared to (15%), indicating that age-bands 6-15 and consume more proportion of their sum insured for hospitalization costs as compared to age-band years. Though, it is observed that age-band Less-than 1 year shows high levels of ratio of number of claims paid to number of members insured and "average claim paid per average sum insured" this apprarent anomaly could be due to incorrect information in 'age' or 'date of birth' fields of members where possibly 0 is filled in. Insurance Information Bureau of India Page 15

17 Policy Premium ( ` in Crs.) Number of Policies Average Amount of Claims Paid (in `) Number of Claims Paid Health Insurance (Non-Life) Data Analysis Report Age and Gender-wise Claims Summary 45,000 Chart 12- Appendix: HR-6 Age and Gender-wise Number of Claims and Average Claim paid ,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 - Less than Above 70 Age-Band (in years) Number of Claims Paid to Males Number of Claims Paid to Females Average Claims Paid to Males (in `) Average Claims Paid to Females (in `) # - Excluding claim records where Claim Paid amount >`20 lakh 200, , , , , ,000 80,000 60,000 40,000 20,000 - Inference: Number of claims paid to males is more than that of females for all age-bands except for the age-bands '16-25' and '26-35' where they are less by 1% and 2% respectively. It is observed that age-band Less-than 1 year shows high number of claims paid as well as an abnormal ratio between male and female. This anomaly could be due to incorrect information in age or date of birth of members where possibly 0 is filled in. Irrespective of gender, the average amount of claim paid is highest for the age-band Above 70 and lowest for age-band 1-5 years. It consistently increases throughout all the age-bands starting from 1-5. Average amount of claim paid per male claimant is more than that of female across all age bands. Type of Cover-wise Claims Summary 6,000 5,000 Chart 13- Appendix: HR-7 Type of Cover-wise Number of Policies and Policy Premium ,000 3,000 2,000 1,000 - Individual Individual Floater Group Group Floater Declaration and Others Type of Cover Policy Premium (` in Crs.) Number of Policies # - Excluding claim records where Claim Paid amount >`20 lakh 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 - Inference: Individual and Individual floaters account for 90 % of number of polices but only 40 % of amount of premiums. With a meagre share of 3% of total health insurance policies issued, group type of policy (Group + Group floater) commands 56% of the total health insurance industry premium. The individual floater policies alone account for 22% of total number of policies and 22% of total policy premium within the range of individual + individual floater type policy covers. Whereas the group floater policies alone account for 84% of total number of policies and 81% of total policy premium within the range of group + group floater type policy covers. Thus group-floaters are more prevalent than group policies and individual policies are more prevalent than individualfloater policies. Insurance Information Bureau of India Page 16

18 Average Amount of Claims Paid (in `) Number of Claims Paid Health Insurance (Non-Life) Data Analysis Report Disease-wise Claims Summary Chart 14- Appendix: HR-8 Disease-wise Number of Claims and Average Claim Paid (in `) ,000 45,000 47,065 41, , ,000 35,000 30,000 25,000 20,000 29,580 22,236 22,483 19,841 16,377 17,944 34,567 27,716 22,338 20,244 17,144 21,098 23,063 18, ,000 10,000 5,000 11,344 10,044 17,857 18, Diseases Number of Claims Paid Average Claim Paid (in `) Average Amount of Claims Paid ( in `) # - Excluding claim records where Claim Paid amount >`20 lakh There are 22 macro groups of diagnosis codes according to ICD-10. The possibility of certain disease group not having sufficient amount of claims data cannot be ruled out. Hence care should be exercised while deriving conclusions from the trend revealed by that particular disease group. Inference: Only 39% out of total claims data set have valid diagnosis codes (ICD-10) which accounts for 10 lacs claim records and ` 2,141 crore claim paid amount. Still this data is credible enough to throw up reasonable trends. The top six highest number of claims paid categories are from disease groups 'INFECTIOUS', 'CLINICAL FINDINGS', 'UROLOGY', 'DIGESTIVE', 'PREGNANCY' and 'INJURY', in that order which account for 64% in number and 53% in claim paid amount. The average claim paid amount is highest for CIRCULATORY, MALFORMATIONS/DEFORMATIONS, ARTHROPATHIES, NEOPLASM and INJURY, in that order. Insurance Information Bureau of India Page 17

19 Average Amount of Claims Paid (in `) Number of Claims Paid Health Insurance (Non-Life) Data Analysis Report State of Hospitalization-wise Claims Summary Chart 15- Appendix: HR-9 State-wise Number of Claims and Average Amount of Claims Paid (in `) ,000 31,556 26,701 30,000 24,897 25,000 22,383 22,510 26,804 22,115 19,611 24,643 23,472 20,000 19,254 20,259 20,068 15,000 17,785 10,993 14,401 14,431 10,000 12, , , ,000-3,921 7, # - Excluding claim records where Claim Paid amount >`20 lakh States Number of Claims Paid Average Claim Paid (in `) Average Amount of Claims Paid ( in `) Inference: 23 States have been classified basing on 44% of total claim records where PIN Code is filled-in. Claim records, where PIN Code is filled-in, account for 11.3 lac claim records and `2,551 cr. claim paid amount. 41% of the total claim records are shared among top 11 states. Like in previous years, Maharashtra leads the states with 22% share in total claims records (excluding claim records where Hospital Pin codes are not available). Gujarat (12%), Tamilnadu (10%) continue to be in top 5 positions for the 5th year in succession. Top six States in terms of number of claims paid, 'MAHARASHTRA', 'GUJARAT', 'WEST BENGAL', 'TAMIL NADU', 'DELHI' and 'KARNATAKA' (in that order) accounts for 72% in number and 76% in claim paid amount. The States, having less than 10,000 claims records each, are 'ORISSA', 'ASSAM', 'GOA', 'BIHAR', 'TRIPURA', 'UTTARAKHAND', 'CHATTISGARH', 'CHANDIGARH' and 'PONDICHERRY'. Considering only those States with more than 10,000 claims records, the top six states of Hospitalization for which average claim paid amount is high are 'DELHI', 'MAHARASHTRA', 'ANDHRA PRADESH', 'HARYANA', 'UTTAR PRADESH' and 'RAJASTHAN', in that order. Further classifying States into Northern, Eastern, Central, Western, Sothern and Union Territories regions, following is observed: REGIONS IN INDIA PROPORTION OF NUMBER OF CLAIMS PAID PROPORTION OF AMOUNT OF CLAIMS PAID WEST INDIA 36% 39% SOUTH INDIA 28% 26% EAST INDIA 13% 10% NORTH INDIA 10% 11% UNION TERRITORIES 9% 13% CENTRAL INDIA 3% 2% Thus Western India contributes to highest number of claims and claim paid amount, followed by Southern India. Central India contributes least number of claims and claim paid amount. Union Territories (where major contributor is DELHI) contribute 'number of claim paid' at second lowest level but contribute 'amount of claims paid' at third highest level, compared to other regions of India. Union Territories (where major contributor is DELHI) contribute to 9% of number of claims and 13% of claim paid amount. Insurance Information Bureau of India Page 18

20 Total Amount of Claims Paid (` in Crs.) Number of Claims Paid Health Insurance (Non-Life) Data Analysis Report Claim Paid Band-wise Distribution of Claims Chart 16- Appendix: HR-10 1, , , , , Claim Paid band-wise Distribution of Claims , , , , , , , ,000 - Claim Paid Band (in `) Total Amount of Claims Paid (` in Crs.) # - Excluding claim records where Claim Paid amount >`20 lakh Number of Claims Paid Inference: 99% of 'total number of claims paid' are below the amount of `3 lakhs which account for 73% share in 'total amount of claims paid'. Maximum number of claims paid falls in the claim paid band of `10,001-`25,000(29%) followed by `25,00 -`50,000(17%). The claims with paid amounts 'less than `1000' account for 13% share in 'total number of claims paid' statistic but contributes only 0.12% to ' total amount of claims paid' statistic. Thus the transaction level data has considerable number of claim records corresponding to negligible amount of claims paid. The claim paid bands 'Above `20,00,000' accounts only for 0.07% share in 'total number of claims paid' statistic but contributes 15% to 'total amount of claims paid' statistic. Thus the transaction level data has negligible number of claim records resulting in extreme values of claims paid amount. Insurance Information Bureau of India Page 19