Maternity, Metro Costs, And Workplace Risks: Data Shows Changing Face of Group Health Insurance Claims

With the rising medical inflation in India, covering healthcare costs at the time of medical emergency is a growing concern. Even in workplaces today, health insurance isn’t just a perk but a necessity. The claims data against Group Health Insurance (GHI) policies reflect this trend wherein employees are relying on group health coverage to meet their healthcare needs.

A recent report by Policybazaar.com, an online insurance marketplace, shows that maternity claims are rising, metro cities are seeing higher costs, and physically demanding jobs are leading to more frequent claims by covered individuals. Stepping up to these rising needs, companies are also adjusting their policies to keep up with such shifts, making employee health benefits more tailored than before.

Let’s take a look at how employees are shaping the claim settlement trends for Group Health Coverage;

1) Gender and Age Trends

If you look at the data, women are filing the most number of claims (at 60 per cent) in comparison to men (40 per cent). The reason behind this? Maternity-related expenses are driving the claim surge by women.

Employees aged between 25 and 35 years are leading these claim numbers as companies offset better maternity benefits to attract and retain talent.

Male employees aged 35-45 have the highest claims, reflecting a rise in lifestyle-related illnesses such as diabetes, cardiovascular diseases, and stress-related disorders.

The trend shows that corporates are increasingly customising age-specific health benefits, such as higher maternity coverage for female employees and wellness benefits for their workforce.

2) Tier 1 Cities Experience the Highest Claim Amounts

It’s a known fact that healthcare costs may differ hugely depending on where you live. The data shows that employees in metro (or Tier 1) cities are seeing the highest average claim amounts, ranging between Rs 1 lakh and Rs 1.25 lakh per case. Expensive private hospitals in these cities that use advanced medical procedures could be one reason behind such high average claim amounts.

In Tier 2 cities, claims range between Rs 70,000 and Rs 80,000 where a balance between private and government healthcare facilities could be driving the lower amount.

Meanwhile, in Tier 3 towns, where public hospitals are more commonly used, claims amount to somewhere between Rs 40,000 and Rs 60,000.

“Companies with operations in Tier 1 cities are opting for higher sum insured policies to protect employees from out-of-pocket expenses. Tier 2 and Tier 3 employers are exploring co-payment and deductible models to keep insurance premiums manageable while maintaining adequate coverage,” the report states.

Reimbursement v/s Cashless Claims: One of the biggest benefits of GHI seems to be cashless claims settlement where employees don’t have to pay upfront for medical treatment. However, access to this benefit also varies depending on the city you live in.

In Tier 1 cities, 60-80 per cent of claims are cashless because of strong hospital networks and insurer partnerships. In contrast, only 40-55 per cent of claims go cashless in smaller towns which also means that employees here often have to cover costs out-of-pocket before getting reimbursed.

Companies in non-metro areas are addressing these gaps by encouraging employees to use insurer-partnered hospitals to maximize cashless benefits. Insurers are also expanding their cashless hospital networks in Tier 2 and Tier 3 cities to increase adoption rates.

3) Who Files the Most Claims?

The data notes that some industries typically see more insurance claims than others, particularly those jobs that are physically more demanding or the employees dealing with hazardous conditions.

These industries lead to frequent medical interventions:

Manufacturing: Workplace injuries, exposure to hazardous materials, and repetitive strain disorders

Construction: High-risk environments with frequent accidents and fractures

Healthcare: Constant exposure to infections, burnout, and musculoskeletal strain from long shifts

Transportation and Logistics: Heavy lifting and prolonged working hours lead to back injuries and joint disorders

However, the report notes that companies are implementing occupational health programs such as ergonomic training, injury prevention workshops, and onsite physiotherapy to reduce workplace-related health risks.

4) New-Age Sectors are Rapidly Adapting Insurance

While physically demanding jobs are seeing the most claims, it’s the tech sector which is setting the bar for how companies approach GHI. These sectors, with rising GHI adoption, highlight a shift in employee benefits strategy, especially in sectors with young, health-conscious workforces.

Here’s what the data compiles;

• New-age startups are attracting top talent by providing comprehensive healthcare benefits to the employees

• E-commerce and online retail are expanding their workforce coverage due to rapid hiring and increasing awareness of insurance benefits

• Fintech and IT are showing a growing demand for mental health, telemedicine, and preventive wellness benefits

All in all, customised and flexible health insurance plans are getting popular with extended coverages such as telehealth, mental wellness support, and stress management programs.

Gym Memberships In Health Plans: Interestingly, companies in tech sectors are also bundling wellness incentives such as gym memberships and health-tracking apps into their policies to encourage proactive health management.

5) Claim Frequency Not That High

The data reflects that while most employees are using their insurance occasionally, only about 5 to 7 per cent of file multiple claims annually. These are typically driven by chronic conditions such as heart disease, respiratory disorders, and joint problems.

To enhance employee benefits, the report notes that companies in turn are restructuring policies to include preventive healthcare measures through regular health check-ups, workplace wellness programs, and chronic disease management interventions.

Early detection programs are also being integrated in some workplaces to identify high-risk employees and prevent serious medical conditions from escalating.

Additionally, the data notes a sharp increase in claims during Q2 (July-September), largely due to the surge in monsoon-related infectious diseases such as dengue, malaria, and typhoid dominate hospitalisation claims. Here, Employees in outdoor jobs (construction, logistics, field sales) are at higher risk.

To counter this, companies must tie up with insurers to cover preventive vaccinations and health screenings before monsoon.

Despite insurance being a workplace necessity, claim rejections can be a frustrating experience for employees. Says Sajja Praveen Chowdary, Director at Policybazaar for Business, “The evolving trends in group health insurance claims highlight the rising cost of medical care and the need for efficient claim processing.”

With rising healthcare costs, changing employee needs, and an increasing focus on preventive wellness, GHI seems to be longer just about covering hospital bills but also to support the general well-being of employees.