Our claims record

Two years, 206 claims, ₹1.34 crore paid — and what the data taught us about designing cover

Our group health claims register, opened up: 206 claims across four corporate policies in two years, ₹1.34 crore settled, every decline explained — and the finding that on one policy 32% of approved hospital bills still never reached the families, because of how the cover was designed.

19 September 2026 · Raja Banka · RHB Wealth Pro, Salt Lake, Kolkata

Drawn from insurer and TPA claim registers for four group health policies, October 2024 to September 2026. Figures are as recorded by the insurer, not by us.

What families are actually afraid of

Nobody buying group health cover is worried about the premium. They are worried about the afternoon when a parent is in a hospital bed, the estimate has crossed six figures, and somebody from a call centre is asking for a document nobody has.

So the only question worth answering with evidence is a narrow one: when a claim is made, does it get paid? Here is our answer, with the register open.

The record, policy by policy

Client names are withheld. The current-year policy is four months old and most of its claims are still moving, so no rate is shown for it — though 25 of its 33 claims already carry an approved amount.

Now the part nobody else publishes: every claim that was not paid

Eleven claims across two years were declined. We are going to list all of them, by reason, because the reasons are the whole story.

Read that list again. Every single decline traces to a line already written in the policy wording — a benefit the cover never carried. Not one was lost because a form was filled in carelessly, because a condition went unmentioned at enrolment, or because nobody followed up.

Every claim that was payable under the policy was paid. The ones that were not payable were never payable, and the family knew it before they were admitted wherever we could reach them first.

That distinction is the entire job. Non-disclosure is the most common reason health claims collapse in India, and it is almost always preventable at enrolment — months or years before anyone is ill. It does not appear once in two years of our registers.

Speed, where it counts

A claim that is eventually paid but takes eleven weeks has still cost the family something. On the retail group’s 2025–26 policy, the median time from complete papers to approval was two days, and 73% of claims were decided within a week — comfortably inside the thirty days IRDAI allows an insurer for a reimbursement claim.

Roughly six claims in ten went cashless, which is the outcome worth engineering for: the family signs at the counter and goes home, and no one is arranging a bridge loan on a Sunday.

Across the country, not just across town

These are Kolkata-headquartered employers, but their people are not. Claims in the register were settled in Kolkata, Bengaluru, Coimbatore, New Delhi and Mumbai, across network and non-network hospitals alike. Distance from our office made no difference to the outcome.

One claim every three working days

Across the twenty-four months in these registers, claims arrived at an average of eight a month — a little over a hundred a year. Not in a tidy stream: the busiest month carried eighteen, the quietest carried two. July 2025 alone brought eighteen families to us at once.

That last pair is worth sitting with. A hundred and twenty-three hospitals is a hundred and twenty-three different billing desks, TPA counters and discharge processes — from large chains in Bengaluru and Mumbai to single-doctor nursing homes in Madhubani, Hazaribag, Uluberia and Sheoraphuli. Each one has its own way of doing things, and each one has to be handled by somebody who has seen it before.

Who the claims are actually for

Here is the figure that surprises most HR heads when we show it to them:

Roughly four claims in five were for somebody other than the employee, and nearly half were for an employee’s mother or father. Dependent-parent claims are the hardest category in Indian group health — older patients, longer stays, more pre-existing conditions, more scrutiny. They are also the ones an employee remembers for the rest of their career.

The patients ranged in age from one year old to eighty-one.

The range of what comes through the door

Two years of registers cover 118 distinct diagnostic codes across essentially every major body system:

• Cancers and blood disorders — including multiple myeloma and anaemia
• Cardiac and circulatory conditions
• Eye surgery, the single largest category on one policy
• Digestive and gastrointestinal admissions
• Orthopaedic work — fractures, joints, the musculoskeletal system
• Genitourinary and gynaecological procedures, including maternity
• Neurological conditions, from essential tremor to vertigo
• Infectious disease — dengue and enteric fever among them
• Accidents, injuries and post-surgical complications
• Respiratory, dermatological and perinatal care

Just over half were surgical admissions and just under half medical management. Individual settlements ran from ₹1,200 to ₹7.67 lakh — a day-care procedure at one end, a major hospitalisation at the other, each needing a completely different conversation with the insurer.

Why the volume is the point

A distributor who files four claims a year is learning on your family’s admission. At a hundred a year, the pattern-matching is already done.

We have seen how a particular insurer treats a cataract package, which hospitals argue about room-category caps, which TPA queries are routine and which ones signal that a claim is about to be declined, and how a pre-authorisation should be worded when a patient is being admitted for observation rather than a named procedure. None of this can be read in a policy document. It is accumulated, one claim at a time.

The reason our declines are all policy exclusions is that we have seen enough claims to know which ones were never going to be paid — and to say so before the family is admitted, rather than after the bill arrives.

Volume also buys standing. An intermediary the insurer’s claims team deals with weekly gets a call returned. One they hear from twice a year does not.

The finding that changed how we design cover

Put two of these policies side by side and something uncomfortable appears. Both were handled by the same people, with the same insurers, in the same two years. The outcomes were not remotely the same.

On Policy A, ₹29 lakh of genuine, approved, non-disputed hospital bills never reached the families. Nothing was rejected. Every one of those claims was passed. The money simply fell into the gaps the policy itself had left.

On Policy B the settled amount came out higher than the original hospital bill — not because anyone was generous, but because pre- and post-hospitalisation heads were claimed on top and nothing ran into a ceiling.

Where the ₹29 lakh went

• The cover ran out. Ten of sixty-three approved claims came within 20% of exhausting the sum insured entirely. Fifty-one of the lives on that policy were covered for ₹2.5 lakh or less — and a single cancer or cardiac admission does not fit inside ₹2.5 lakh.
• The corporate buffer was never used. Across all seventy-three claims, the buffer drawn was zero — while ten claims were scraping the ceiling. A buffer exists precisely for those ten.
• Consumables. Read the itemised deductions and it is gloves, cotton, betadine, nebuliser charges, syringe-pump charges, registration fees, a blood-group test. Individually trivial. Together, lakhs.
• Room category. Where the policy caps the room and the family goes one grade up, the proportionate deduction applies across the whole bill, not just the room.

Not one of those four things is an insurer behaving badly. All four were decided months earlier, at the design table, by people who had never seen a claims register.

Which is why we design the policy from the claims data, not from a brochure

Two hundred and six settled claims is not just a track record. It is a dataset — and it is the one thing a broker quoting you on price does not have.

When we are asked to structure or renew a group health policy, we do not start from a benefit sheet. We start from what actually happened to a hundred families a year:

• Sum insured is set against real claim sizes, not against the premium budget. We know what an eye surgery, a cardiac admission and an oncology cycle actually cost at the hospitals your people use, because we have paid those bills.
• Parental cover gets the attention it deserves. Forty-four per cent of claims are for employees’ parents. That is where the money goes, and that is where sub-limits quietly do the most damage.
• Consumables and room-rent terms are negotiated up front, because we can show an underwriter, with numbers, exactly what those two clauses cost a workforce over a year.
• A corporate buffer is sized and, crucially, made usable — with the trigger written so it can actually be invoked when a claim hits the ceiling at 11pm.
• Pre- and post-hospitalisation windows are checked, because they are the cheapest benefit in the policy and the most often left on the table.

The test of a group health policy is not its premium and not its brochure. It is the share of a real hospital bill that a real family ends up paying. We are one of very few distributors in a position to tell you that number in advance — because we have two years of it, written down.

What the register carries

Clients sometimes ask how we can be so specific. The answer is that every claim is tracked on a structured register, and every field on it has earned its place by having mattered on some earlier claim:

That last field is the one most registers do not keep. It is also the only one that tells you how to write next year’s policy.

What we actually do for this

• Before the policy. Enrolment is where claims are won. Declared conditions get underwritten and priced; undeclared ones become disputes two years later. We chase the disclosure nobody wants to make.
• Before admission. One call tells you whether the hospital is in network, what room category the policy entitles you to, and whether the procedure is covered at all. That call is why the exclusion list above contains no surprises.
• During. The pre-authorisation, the queries and the discharge clearance are handled by us, not by a family standing in a corridor.
• After. Pre- and post-hospitalisation heads are claimed properly. On one policy the amount finally settled exceeded the amount originally billed, because those heads were pursued.

This is unglamorous work. It is also the difference between a policy document and a policy that pays.

Questions this raises

What is RHB Wealth Pro's health insurance claim settlement record?

Across four corporate group health policies between October 2024 and September 2026, 206 claims were handled and ₹1.34 crore was settled. In the completed policy years, 96% of decided claims were paid. Eleven claims were declined in total, every one of them for a benefit the policy did not carry.

Why were claims declined, and were any rejected for non-disclosure?

None were declined for non-disclosure, concealment or misrepresentation. The recorded reasons were outpatient treatment not covered (6), documentation the insurer could not obtain (2), a hospital stay under 24 hours (1), sterility and infertility as an express exclusion (1), and one case the insurer held was manageable without admission.

How quickly are group health claims settled?

On one corporate policy the median time from complete papers to approval was two days, and 73% of claims were decided within a week. IRDAI allows an insurer thirty days to decide a reimbursement claim once documentation is complete.

How many group health claims go cashless?

Roughly six in ten claims in our register were settled cashless, meaning the family signed at the hospital counter rather than funding the bill and claiming it back.

Does RHB Wealth Pro handle claims outside Kolkata?

Yes. Claims in the register were settled in Kolkata, Bengaluru, Coimbatore, New Delhi and Mumbai, at both network and non-network hospitals. The employers are Kolkata-headquartered but their employees are spread across India.

How many health insurance claims does RHB Wealth Pro settle each year?

About 103 a year on average across the last two years — 206 claims over twenty-four months, or roughly eight a month. The busiest single month carried eighteen claims.

What kinds of medical conditions are covered in these claims?

118 distinct diagnostic codes across essentially every major body system: cancers and blood disorders, cardiac and circulatory conditions, eye surgery, digestive and orthopaedic admissions, genitourinary and gynaecological procedures including maternity, neurological conditions, infectious diseases such as dengue and enteric fever, accidents and injuries, and respiratory, dermatological and perinatal care. Patients ranged from one year old to eighty-one.

How many hospitals has RHB Wealth Pro dealt with?

123 different hospitals across 35 cities in nine states, ranging from large hospital chains in Bengaluru and Mumbai to single-doctor nursing homes in smaller towns, and covering both network and non-network facilities.

Who do most group health claims get made for?

Roughly four in five claims were for someone other than the employee. Forty-four per cent were for an employee's parents, thirty-four per cent for a spouse or child, and twenty-two per cent for the employee themselves. Dependent-parent claims are the hardest category in Indian group health.

Can a health insurance claim be approved and still leave the family out of pocket?

Yes, and it is common. On one corporate policy in our register, ₹90.5 lakh of hospital bills were submitted on approved claims and only ₹61.3 lakh was settled — 32% of the bill was borne by the families even though nothing was rejected. The gap came from the sum insured running out, an unused corporate buffer, non-payable consumables and room-rent limits, all of which are decided when the policy is designed rather than when the claim is made.

How does claims data help in designing a group health policy?

It sets the sum insured against what admissions actually cost rather than against the premium budget, gives the parental-cover terms the weight they deserve when 44% of claims are for employees' parents, provides an underwriter with evidence of what consumables and room-rent clauses cost a workforce over a year, sizes a corporate buffer and makes its trigger usable, and checks the pre- and post-hospitalisation windows that are most often left unclaimed.

What is a corporate buffer in group health insurance and why does it matter?

A corporate buffer is a shared pool the employer can draw on when an individual claim exhausts a member's sum insured. In one register we analysed the buffer drawn across seventy-three claims was zero, while ten of those claims came within 20% of exhausting the cover entirely. A buffer that is sized correctly and whose trigger is written so it can actually be invoked is what catches exactly those cases.