Who the policy pays for

An employee health policy also serves the family members covered under it, and those claims can have a different cost pattern from the employee's own. In this book, parents generate fewer claims than employees but more incurred cost. Children account for a smaller share of the money than of the claims. The two comparisons show why the number of claims and their cost need to be read together.

Across the 74,339 claims recorded under Loop's corporate health policies in the latest twelve-month window, employees account for 33.5% of claims and 32.2% of incurred cost. The rest, mainly for spouses, children and parents, account for 67.8% of incurred cost. Incurred is the recorded policy cost, including amounts on claims still open; it is not confirmation that the money has been paid out.

Two in three claims are not the employee's#

A group policy can be measured two ways. Count the claims and you are measuring how often the policy is used. Count the rupees and you are measuring what the policy costs. The two views rank the same four groups differently.

For every hundred claims the employee files, the parent files eighty-eight. For every hundred rupees of incurred expense the employee creates, the parent creates one hundred and fifteen. That is the whole distinction in one pair of numbers. Both are group totals, not the rate at which any individual claims. The parent group is slightly smaller than the employee group by count and slightly larger by cost.

The child group leans the other way, 14.3% of claims against 9.4% of the money, and of the three groups that lean that way it leans furthest. Employee and spouse claims tilt in the same direction far more gently, at 33.5% against 32.2% and 22.7% against 21.5%. The parent group is the only one of the four that tilts the opposite way.

None of this says anything about how sick anyone is. A claim is a record of a bill, not of a diagnosis or of a population, and the mix of who claims on a book is partly a mix of who each employer chose to cover. Some plans include parents and some do not. Read the parent share as a fact about this book, not a rate of illness in the population.

The most frequent category of claim averages ₹2,336 to ₹4,143 across the four groups#

The category that appears most often is not the one that carries the most incurred cost.

General health services is the most frequent category on the book. It collects the records whose ailment text describes someone encountering health services rather than a named condition. It is the most frequent kind of claim the employee group files, at 19.1% of its claims and an average of ₹2,683. It is second in the child group at 20.0% and ₹2,336, second in the spouse group at 11.9% and ₹2,366, and second in the parent group at 12.6% and ₹4,143.

So roughly one claim in five from employees, and one in five from their children, falls in a category whose average claim is a few thousand rupees rather than a few tens of thousands. Those claims are close to invisible when categories are ranked by the rupees they carry, and they lead when the same categories are ranked by how often a claim arrives.

Average cost per claim runs from ₹28,419 to ₹53,981 across the four groups#

The four groups do not claim for the same things, and the ranking changes depending on which column you read.

The employee group claims most often for general health services and infections, at 19.1% and 12.7% of its claims. Musculoskeletal, injury and fractures is its largest category by incurred cost, averaging ₹83,660 a claim.

The spouse group is dominated by one category. Maternity and delivery is 35.8% of spouse claims and leads the group's incurred cost, accounting for over a third of claims and cost. This is why maternity is a cost page in its own right. Set maternity aside and what remains looks much like the employee's mix: general health services, infections, gastrointestinal.

The child group has the lowest average per claim of the four, at ₹28,419. Infectious disease and fever is nearly a quarter of its claims, averaging ₹27,672; general health services another fifth, averaging ₹2,336; respiratory a further 13.4%. Neonatal disorders is the group's third-largest category by rupees: newborn care, which this report's category rules record in its own category rather than inside maternity and delivery.

The parent group is the one that looks least like the rest. Its most frequent category is eye and cataract, averaging ₹30,620 a claim. Its largest cost categories are different.

Three categories carry more than a third of the parent group's cost#

Three categories together account for about one parent claim in five and more than a third of the group's incurred cost. Cardiac and circulatory claims alone average ₹1.16 lakh, roughly twice the parent group's own average and four times the average child claim. Meanwhile the two most frequent parent categories, eye and cataract and general health services, are between them just over a quarter of the group's claims and about 9% of its incurred cost.

Those three categories fall differently on the two sides of the parent group. Cardiac and circulatory has a larger incurred share on the father side, while musculoskeletal, injury and fractures has a larger share on the mother side; cancer and oncology is close to level. These are relationship labels on a claim record rather than the record's sex field, which is a different instrument and a different set of claims. Parent claims takes this group apart in more detail.

Average cost per parent claim also climbs across the age bands, which no frequency ranking shows.

Claim shares use all parent claims as their base; incurred shares use all parent incurred cost. A usable age is recorded on 94.1% of parent claims. The 5.9% without one sit in no age band, and their incurred cost is also outside the bands shown. The columns therefore stop short of 100%.

A parent claim in the 80-plus band averages more than twice one from a parent under 50. Nearly six in ten parent claims come from the 60-to-79 bands, and those are also the bands where the group's share of the rupees runs ahead of its share of the claims. This is a comparison between age bands inside a single twelve-month window, not a measurement of anyone's costs changing as they age.

Male claims average more than female claims in all four groups#

The male average exceeds the female average by 22.2% in the employee group, 29.0% in the spouse group, 14.7% in the child group and 11.1% in the parent group, each expressed as a share of that group's female average.

These are averages over the claims whose sex is recorded, which is between 91.8% and 94.1% of a group's claims depending on the group. They say what a recorded claim cost. They do not say how often anyone claimed, and neither column is a rate per covered life.

The gap between the amount claimed and the amount incurred is widest on parent claims#

The claims data has fields for the amount claimed and the amount incurred. The claimed amount is what was submitted on the claim, which is not necessarily the hospital's total bill. The report does not publish the aggregate sums; the table shows two relative measures for each group.

Of the four groups, parent claims carry the widest gap between the amount claimed and the amount incurred, at 33.6%, and employee claims the narrowest, at 28.9%, a spread of 4.7 percentage points. It falls on the group with the highest average per claim of the four.

What it is not is a measurement of what any household paid. The difference between two recorded amount fields is arithmetic, not an account of who absorbed the remainder, and in each of the four groups the coded deduction reasons come to less than the full gap.

Figures count claims, not people; without covered-life totals they cannot give a claiming rate per member. Non-employee includes every other relationship. Averages include zero-incurred claims. Incurred is recorded cost, including open claims—not cash paid or household spending. Methodology.