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Health Insurance (Non-Life

Commercial) Data Analysis Report

2016 - 2017

Insurance Information Bureau of India


Health Insurance (Non-Life) Data Analysis Report 2016 - 2017

The information used in this study is based on data provided by the Insurers. IIB does not guarantee the accuracy
or completeness of the information given. In no event shall IIB be liable for any errors or omissions, regardless of
the cause, or for any loss or damage arising in connection with the use of this information.

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017

CONTENTS
1.INTRODUCTION ....................................................................................................................................... 3
2.DATA ........................................................................................................................................................ 4
3.EXECUTIVE SUMMARY ............................................................................................................................ 4
4.MACRO INDICATORS ............................................................................................................................... 5
5.DETAILED ANALYSES
Product Type-wise Claim Summary ............................................................................................................. 6
Age and Gender-wise Claims Summary....................................................................................................... 7
Disease-wise Claims Summary .................................................................................................................... 8
Claim Paid Band-wise Distribution of Claims ............................................................................................. 9

6.APPENDICES........................................................................................................................................... 10
7. OBSERVATIONS/CAVEATS ....................................................................................................................... 12

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017

1. INTRODUCTION

Trend in Health Insurance Business

As per IRDA Annual Report 2016-17, the health insurance segment achieved a growth rate of 25.75 percent in
gross premium, which is the highest reported during the past five years. However, the share of health segment
has decreased to 26.95 percent from 28.49 percent of previous year. Over the past five years, the share of
private sector general insurers declined from 27 percent in 2012-13 to 19 percent in 2016-17 while the share of
standalone health insurers moved up from 11 percent to 18 percent and the share of public sector general
insurers remained stagnant at 63 percent. Health Insurance Business can be classified into Government
sponsored health insurance, Group health insurance (other than Government sponsored) and individual health
insurance. The share in premium of Group business was the highest at 48 percent followed by individual
business (42 percent) and Government (10 percent). In terms of number of persons covered under health
insurance, three-fourth of the persons were covered under government sponsored health insurance schemes
and the balance one-fourth were covered by group and individual policies issued by general and health insurers.

The Value of Healthy Data

Insurance Companies are rife with data and the challenge is to make use of this data to make informed decisions
while enhancing efficiency of the portfolio. While lot of initiatives are being taken by different stakeholders to
promote health awareness and the need for mitigating health risks, it is the insurance companies that have to
prove that they add value to the healthcare equation. One key challenge towards obtaining meaningful insights
out of the data is to capture core fields – both at the insurer and provider level. Assigning risk scores to specific
claims and providers, identifying aberrations in claims, billing patterns, cost trends, relook at product pricing are
some of the value adds that can be derived through incisive analysis of the data. The inherent importance of
data lies in its ability to drive decision-making through strategically executed analytics.

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017

2. DATA

The Insurance Information Bureau of India has been collecting transaction level data on Health Insurance
policies, members and claims through online mode (i.e. uploading on to the IIB-website on monthly basis) from
all non life insurance and standalone health insurance companies in India. The online mode commenced from
financial year 2010-11.

The Health data are collected in 3 formats.

1. Policy Data
2. Members Data
3. Claims Data

The data submitted are subjected to certain validation checks to prevent transaction data with some
inconsistencies from entering the IIB data base.
The data received from Insurers for the year 2016-17 have been analyzed and analyses in the following pages
generated for the information/ use of all the stake holders.

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 are shown in the respective
tables. Given the large size of data, despite these deficiencies, the trends / conclusions arrived at may be
sufficiently representative of the whole population.
3. Executive Summary:
Product Type-wise Claim Summary (Chart 1- Appendix: HR-1):

Health insurance market is dominated by Hospitalization Indemnity Product and package policies

Age and Gender-wise Claims Summary (Chart 2- Appendix: HR-2):

The number of claims paid and amount of average claim paid to males is more than that of females
across most of the age-bands.

Disease-wise Claims Summary (Chart 3- Appendix: HR-3):

 Only 45% out of total claims data set have valid diagnosis codes(ICD-10)
 Claim number-wise top six disease groups are 'Certain infectious and parasitic diseases', 'Symptoms
signs and abnormal clinical and laboratory findings not elsewhere classified ', 'Health Services
Related', 'Diseases of the genitourinary system', 'Diseases of the digestive system', ' Diseases of the
eye and adnexa'
 The average claim paid amount is highest for the following six Disease groups: ‘Diseases of the
circulatory system', 'Diseases of the musculoskeletal system and connective tissue', 'Neoplasms',
'Injury, poisoning and certain other consequences of external causes', 'Diseases of the nervous
system', ‘Diseases of the digestive system'

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017
Claim Paid Band-wise Distribution of Claims (Chart 4- Appendix: HR-4):

 99% of 'total number of claims' are below the amount of `3 lakhs which account for 86% share in
Claim paid amount
 Almost one-third of number of claims fall in the claim paid band of `10,000-`25,000

4. MACRO INDICATORS

Financial Year No. of No. of Premium in ` Lakh Claims


policies Persons Incurred(Net) in
Covered in '000 ` Lakh

2011-12 81,79,898 72,830 10,84,385 7,80,407

2012-13 89,39,429 57,904 13,10,498 9,41,815

2013-14 99,94,013 60,944 15,41,261 12,35,316

2014-15 1,08,99,253 73,666 17,67,083 15,15,346

2015-16 1,18,15,498 85,690 21,97,350 18,44,834

2016-17 1,31,37,093 1,02,440 27,30,124 21,43,014

Sources:
 IRDAI Annual Reports of respective years and Handbook

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017
5. DETAILED ANALYSES
Product Type-wise Claims Summary
Chart 1- Appendix HR-1

Excluding Claim Records where Claim Paid Amount is less than 1,000 and greater than 20 lakh

Excluding Claim Records where Claim Paid Amount is less than 1,000 and greater than 20 lakh

Inference:
 Health insurance market is dominated by Hospitalization Indemnity Product and package policies which
together account for 97% of number of claims and 95% of Claim paid amount.

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017

Age and Gender-wise Claim Summary


Chart 2- Appendix: HR-2

Excluding Claim Records where Claim Paid Amount is less than 1,000 and greater than 20 lakh

Excluding Claim Records where Claim Paid Amount is less than 1,000 and greater than 20 lakh

Inferences:
 No. of claims paid to males is more than that of females for all age-bands except '16-25' , '26-35' and
'46-55'
 The amount of average claim paid for males is greater than that of females for all age bands except ‘6-
15' and ’66-70’ where they almost converge and 'above 70' where it is less than that of females.
 For both the genders the highest average claim paid amount is in the age band 'above 70'.

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017
Disease-wise Claims Summary
Chart 3- Appendix: HR-3

Excluding Claim Records where Claim Paid Amount is less than 1,000 and greater than 20 lakh

Excluding Claim Records where Claim Paid Amount is less than 1,000 and greater than 20 lakh

There are 22 macro groups of diagnosis codes according to ICD-10. The possibility of certain disease groups not having sufficient amount of claims data
cannot be ruled out. Hence care should be exercised while deriving conclusions from the trends revealed by those disease groups.
Inferences:

 Only 45% out of total claims data set have valid diagnosis codes(ICD-10) that also with only the first
three characters of Diagnosis field being reliable. They account for 24.3 lakh claims and 7,994 crore
claim paid amount
 Claim number-wise top six disease groups are 'Certain infectious and parasitic diseases', 'Symptoms
signs and abnormal clinical and laboratory findings not elsewhere classified ', 'Health Services
Related', 'Diseases of the genitourinary system', 'Diseases of the digestive system', ' Diseases of the
eye and adnexa', in that order which account for 57% in number and 40% in claim paid amount,
considering only those records where diagnosis code was properly filled-in

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017
 The disease groups having less than 10,000 claims each are 'External causes of morbidity and
mortality', ‘Congenital malformations, deformations and chromosomal abnormalities', 'Mental and
behavioural disorders' and 'Codes for special purposes'

 Considering only those Disease groups with more than 10,000 claims, the average claim paid
amount is highest for the following six Disease groups: ‘Diseases of the circulatory system', 'Diseases
of the musculoskeletal system and connective tissue', 'Neoplasms', 'Injury, poisoning and certain
other consequences of external causes', 'Diseases of the nervous system', ‘Diseases of the digestive
system' in that order.

Claim Paid Band-wise Distribution of Claims


Chart 4- Appendix: HR-4

Excluding Claim Records where Claim Paid Amount is less than `1,000 and greater than `20 lakh

Inference:
 99% of 'total number of claims' are below the amount of `3 lakhs which account for 86% share in
Claim paid amount, replicating experience of last year
 Almost one-third of number of claims paid fall in the claim paid band of `10,000-`25,000

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017

6. APPENDICES
HR-1: Product Type- wise Claim Summary – 2016-17
Total_Claim_Paid_Amoun Share of No of Share of Claim
Number_of_Claims
PRODUCT_TYPE t(in Cr.) Claims % Paid Amount %

Hospitalisation Indemnity Policy 3532199 11953 65.79 66.62


Hospital Cash Plan 34572 106 0.64 0.59
Critical Illness Cover -Indemnity 82 1 0.00 0.00
Critical Illness Cover - Benefits 257 5 0.00 0.03
Out Patient Policy 9534 5 0.18 0.03
Universal Health Policy 149 2 0.00 0.01
Micro insurance Policy 1640 2 0.03 0.01
Package Policy 1667468 5123 31.06 28.55
Hybrid Policy 15438 71 0.29 0.39
Any Other Product 107508 677 2.00 3.78
Total 5368847 17943 100 100

HR-2: Age–Band and Gender- wise Number of Claims, Claim Paid Amount (in cr.) and Average Claim Paid Amount – 2016-17
Age-
Average Claim
Band(in Number of Claims Total Claims Paid Amount (in Cr.)
Paid Amount
Years)
Male Female Total Male Female Total Male Female Total
2,87,916 2,30,631 5,18,547 980 488 1,468 34,052 21,142 55,194
[0-5]
396 247 643 25,312 25,326 50,639
[6-15] 1,56,526 97,396 2,53,922
2,11,894 2,70,179 4,82,073 650 662 1,312 30,676 24,491 55,167
[16-25]
3,19,984 4,09,804 7,29,788 946 1,128 2,073 29,561 27,515 57,076
[26-35]
2,79,348 2,37,467 5,16,815 1,173 787 1,960 41,976 33,143 75,119
[36-45]
2,79,242 3,15,787 5,95,029 1,149 1,105 2,254 41,146 34,995 76,141
[46-55]
1,98,287 1,49,737 3,48,024 754 556 1,310 38,001 37,144 75,144
[56-60]
1,67,855 1,32,285 3,00,140 706 523 1,228 42,038 39,524 81,562
[61-65]
1,30,905 97,987 2,28,892 526 397 923 40,203 40,499 80,702
[66-70]
[Above 1,45,954 93,250 2,39,204 623 463 1,087 42,711 49,686 92,396
70]
[Age Not 1,03,109 73,060 1,76,169 376 250 627 36,497 34,249 70,746
Specified]
22,81,020 21,07,583 43,88,603 8,279 6,605 14,884
Total 36,296 31,339 33,916

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017

HR-3: Disease-wise Number of Claims, Amount of Claims Paid and Average Claim Paid -2016-17
Average_Claim Share of No of Share of Claim
Disease Number of Total_Claim_Paid_A
Disease Name _Paid_Amount Claims % Paid Amount %
Code Claims mount(in Cr.)
V01-Y98 ACCIDENT 9585 40 41438 0.39 0.50

M00-M99 ARTHROPATHIES 85689 555 64817 3.52 6.95

D50-D89 BLOOD DISEASES 15090 54 36021 0.62 0.68

I00-I99 CIRCULATORY 166610 1154 69261 6.85 14.44

CLINICAL
R00-R99 250366 520 20774 10.30 6.51
FINDINGS

CODES FOR
U00-U99 37 0 35857 0.00 0.00
SPECIAL PURPOSES

K00-K93 DIGESTIVE 211181 763 36133 8.68 9.55

H60-H95 EAR 17569 55 31363 0.72 0.69

E00-E90 ENDOCRINE 56498 179 31714 2.32 2.24

H00-H59 EYE 181569 427 23529 7.47 5.34

HEALTH SERVICES
Z00-Z99 247684 146 5882 10.19 1.82
RELATED

A00-B99 INFECTIOUS 257544 585 22715 10.59 7.32

S00-T98 INJURY 135809 664 48896 5.58 8.31

MALFORMATIONS
Q00-Q99 4916 32 65694 0.20 0.40
/DEFORMATIONS

MENTAL
F00-F99 4240 13 30658 0.17 0.16
DISORDERS

C00-D48 NEOPLASM 143000 748 52292 5.88 9.35

G00-G99 NERVOUS 36002 168 46670 1.48 2.10

PERINATAL
P00-P96 PERIOD 23014 69 33872 0.95 0.86
CONDITIONS

O00-O99 PREGNANCY 147020 469 29814 6.05 5.87

J00-J99 RESPIRATORY 159486 453 31897 6.56 5.66

L00-L99 SKIN 35616 103 28394 1.46 1.29

N00-N99 UROLOGY 243178 796 29045 10.00 9.96

Disease_Not
Not Specified 2937144 9949 33872
Specified

Total 5368847 17943 33420

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017
HR-4: Distribution of Claims by Claim Paid Band - 2016-17
Number_of_Clai Total_Claim_Paid_Amou Share of Claim Paid
Claim_Paid_Band Share of No of Claims %
ms nt(in Cr.) Amount %
[1000-5000] 1156641 298 21.54 1.66

[5000-10000] 722069 532 13.45 2.97

[10000-25000] 1565519 2667 29.16 14.87

[25000-50000] 1059411 3700 19.73 20.62

[50000-75000] 361710 2175 6.74 12.12

[75000-100000] 158865 1368 2.96 7.62

[100000-300000] 296019 4769 5.51 26.58

[300000-500000] 33757 1243 0.63 6.93

[500000-1000000] 12705 899 0.24 5.01

[1000000-1500000] 1530 183 0.03 1.02

[1500000-2000000] 621 109 0.01 0.61

Total 5368847 17943 100 100

OBSERVATIONS/CAVEATS:
 CignaTTK Health Insurance Company Limited, Max Bupa Health Insurance Co.Ltd., Aditya Birla Health
Insurance Co Ltd., and SBI General Insurance Company Ltd have not completed their data submission
for 2016-17.
 Oriental Insurance Co. Ltd., United India Insurance Co. Ltd., National Insurance Co. Ltd., CignaTTK
Health Insurance Company Limited, Bharati AXA General Insurance Co. Ltd., SBI General Insurance
Company Ltd., Max Bupa Health Insurance Co.Ltd.,and Raheja QBE General Insurance Co.Ltd.have not
submitted Financial Reconciliation (2016-17) statement yet. Hence, shortfalls in submission have not
been quantified.
 Insurers did not submit membership data to the tune of 5.84 Cr. (57%)
 Under the section “Detailed Analyses” the data records with amount of claims paid less than Rs.1000/-
and greater than Rs.20,00,000/- have been excluded so as not to get the analyses distorted
 The gender is specified for 82% of total claims records.
 8% of total number of claims paid have incorrect information about age.
 Only 45% out of total claims data set have valid diagnosis codes(ICD-10) that also with only the first
three characters of Diagnosis field being reliable. They account for 24.3 lakh claims and 7,994 crore
claim paid amount
 Tabulations & Charts in the report are generated from the data supplied by Non-Life Insurers for the
period 2016-17 through online mode of data submission.
 Aggregate data were collated from the transaction level data supplied by non-life Insurers
 Classification of Diseases has been done based on ICD-10 Codes to the extent provided by the non-life
Insurers
 The Tables are indicative and contextual.
 Findings reflected here are only illustrative and not conclusive.

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Health Insurance (Non-Life) Data Analysis Report 2016 - 2017
 The information contained in the tables cannot be the subject matter for any disputes/litigation
affecting IRDA/IIB/Insurance Companies/ Insurance Intermediaries.

Disclaimer
This Report is based on the data received from Insurance Companies in India and data and information from various other
sources. Insurance Information Bureau of India (IIB) does not warrant the accuracy of any advice, opinion, statement,
representation or other information contained in this Report. No one should act solely based on the contents of this Report,
without seeking appropriate professional advice.

Your use of the materials and information contained therein, is solely at your own risk, and IIB and its affiliates shall not be
held liable for any loss or damages whatsoever, sustained by any person or entity which relies on the information contained
therein.

IIB disclaims all liability in respect of actions taken or not taken by any person or entity, based on the contents of this
Report or any loss or damage whatsoever arising in connection with the use of information contained in this Report by such
person or entity.

About IIB
Insurance Information Bureau (IIB) was established by the Insurance Regulatory & Development Authority of India (IRDAI)
as a single platform to meet the data needs of the Insurance industry, in 2009.

IIB fills the need for a sector–level data repository and analytics which would empower stakeholders through provision of
accurate, timely, reliable insurance data and analysis. The Bureau is also mandated with the responsibility of throwing
insights on issues of strategic importance by generating reports through deployment of advanced analytics.

IIB will provide information support on a complete, consistent, and concise manner, to all stakeholders associated either
directly or indirectly with the Insurance sector, including insurers, regulator and government agencies.

The Bureau was formally registered as a Society with Registrar of Societies, Government of Andhra Pradesh, in November
2012. The society is governed by a Governing Council with 20 members consisting of experts from the insurance sector,
technology and management experts and eminent academicians. The council also consists of ex-officio members from the
Life and General Insurance Councils, and members of the board of IRDAI.

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