Who the Policy Pays For

Of 74,339 hospital claims and ₹320.6 crore of incurred expense Loop's broker book absorbed in the latest twelve months, only one in three claims came from the employee. The other two-thirds were filed on behalf of a spouse, a child, or — most expensively — a parent. The standard year-end claims slide at most Indian employers buries this. Group-health spend is presented by employee. Cost per covered life. Loss ratio against premium paid. The structural reality the 2026 data shows is that the group policy in modern Indian corporate practice is, in claim terms, paying for roughly two other people for every employee it nominally covers.

One in three claims is filed by the employee#

The parent layer files nearly as many claims as the employee, at a meaningfully higher cost per claim, and produces the single largest share of incurred expense in the policy. 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. The employee is, in claim-volume terms, a minority customer of their own health policy.

The four layers are clinically distinct populations#

The relationships don't just claim at different volumes. They are different populations, presenting with different conditions.

Age distribution by layer:

The age table tells the story before the condition table does. The four layers don't overlap. The employee and spouse are working-age (75% of employees, 80% of spouses between 18 and 45). The child layer is paediatric. The parent layer is retirement-age and post-retirement — 78% between 56 and 75, another 8% over 76. Four populations, four very different bodies.

The clinical mix follows.

The employee is in the policy for injury and infection — the claim mix of an active working body. The spouse layer is dominated by maternity, which on its own accounts for roughly 36% of spouse claims and 37% of spouse incurred. The child layer is paediatric infectious disease — viral fevers, bronchitis, pneumonia, gastroenteritis. The parent layer is the late-life chronic-disease load that the Indian healthcare system was, until very recently, not designed to absorb at all.

The three largest single lines across the whole bill:

The parent layer is the only one that prefers cashless#

Cashless versus reimbursement is the single most operationally consequential split in a group-health policy. Cashless means the insurer pays the hospital directly at discharge; reimbursement means the patient pays the hospital, submits the bill afterwards, and waits six-to-twenty days for the money. The first is unambiguously the smoother household experience.

The parent layer is the only one of the four where cashless exceeds reimbursement. The clinical reason: parent admissions concentrate in conditions — cardiac, oncology, fracture surgery — large enough in absolute cost to justify going to a network hospital, and complex enough to require the kind of pre-authorisation that cashless requires. The working-age layers above them claim more often for the smaller event at the local hospital, where network discipline doesn't always reach.

Query rate (insurer requesting clarification) follows a different pattern. Spouse claims trigger the most queries at 24.3% — driven by maternity documentation. Parent claims trigger fewer, at 19.8%, against the natural intuition. The parent claims are bigger, cleaner, faster.

Male claims cost more in every layer#

The gender composition of each relationship layer is structural — it reflects who's on the policy and why.

The employee population in our sample is roughly 2.4× more male than female — a structural feature of corporate India's gender mix in the sectors most represented (IT, BFSI, manufacturing). The spouse layer is overwhelmingly female because the predominantly male employee base brings predominantly female spouses onto the policy. The parent layer is, helpfully, balanced.

Within each layer, male claims cost more on average than female claims — consistently, across all four.

The spouse layer gap is partly an artefact — female spouse claims include a large share of maternity admissions, which are relatively cheap per claim; the rare male spouse claims skew to more serious conditions. The persistent 10-18% gap across employee, child, and parent reflects the male skew toward higher-severity admissions documented in the international claims literature.

The parent layer is where the gender split is most revealing because the population is balanced. The claim mix is highly category-specific.

Fathers and fathers-in-law concentrate in cardiac and genitourinary categories — the conditions that drive most of the per-claim cost in the parent layer. Mothers and mothers-in-law concentrate in fractures and oncology. The fracture pattern reflects post-menopausal bone density loss; the cardiac pattern reflects the well-documented later onset of cardiac disease in women relative to men, which is also a higher-severity onset when it arrives. The eye/cataract line is roughly balanced, as it would be in any aging population.

The employee layer's gender × category split is similarly structural.

Two structural notes. Maternity is 99% female by definition (the 17 male claims are coding artefacts, likely partner accommodation costs). And musculoskeletal injuries are 90% male — male employees are 8.6× more likely than female employees to be in for an MSK claim, reflecting both the gender composition of jobs with physical exposure and the gender pattern of commuting-injury data.

The bigger the company, the more the parent dominates#

Indian corporate health policies are sold in tiers. Enterprise plans typically include parental coverage by default; SME plans often exclude it or pass the cost back to the household.

The pattern is monotonic. As the employer gets larger, the share of claims coming from the parent layer climbs from one in seven (SME) to roughly one in three (Enterprise). The mid-market sits in between.

Parents are admitted where their employee children work#

Parents are admitted, in most cases, in the city the employee works in — not the tier-2 hometown where the parent independently lives.

The implication for plan design: the network the policy needs in the metros is also the network the parent layer needs. The hospital city is, in nearly all cases, the employee's metro. This is a quiet generational signal — the Indian corporate group-health policy is the financial backbone of an increasingly co-located multigenerational household.

Spouse claims are maternity-dominated; child claims are cheap and paediatric#

The two middle layers are easy to overlook in the cost-headline conversation. They shouldn't be.

Spouse layer. 22.7% of claims, 21.5% of incurred. Average claim ₹40,849 — almost identical to the employee. Maternity is the largest single line: roughly 36% of spouse claims and 37% of spouse incurred. Strip maternity out and the remaining spouse claim mix looks like the employee's. In this dataset, the working-age Indian woman costs the policy roughly what the working-age Indian man costs it, claim for claim, once maternity is separated out.

Child layer. 14.3% of claims, 9.4% of incurred — the only layer where claim share exceeds cost share. Average claim ₹28,419, the lowest of the four. Dominated by infectious-disease and respiratory admissions. The neonatal disorders line is small in volume but worth flagging — it's the early-life cost that emerges when a maternity admission produces a baby who needs intensive care, and which the policy then carries into a separate claim trail.

The actuarial price of a parent-heavy policy isn't the price of an employee-only one#

Three structural facts the 2026 data establishes:

Open questions for WHI 2027#