The Shape of the Bill

Loop's broker book absorbed ₹320.6 crore of incurred hospital cost across 74,339 claims in the latest twelve-month window. That is the bill this section takes apart — by who it was paid for, what conditions drove it, how it moved through the claims machinery, and where it concentrated. The number sits inside a much larger one. Hospitals and patients submitted ₹470.2 crore of claims to get to that ₹320.6 crore. The 74,339 claims are filed against roughly 964 distinct company policies, covering the spouses, children, and parents of urban employees alongside the employees themselves. The pages that follow dissect each of those dimensions. This one establishes the aggregate shape they are dissecting.

A third of the claimed amount never becomes an incurred cost#

The single most important distinction in any claims book is the difference between what is asked and what is paid. In this window, ₹470.2 crore was claimed and ₹320.6 crore was incurred. The ₹149.6 crore gap between them — 31.8% of the claimed amount — is the portion the insurer and its third-party administrators did not carry.

The shave is not a single mechanism. The deduction field on the claim record — which tags items like non-medical consumables, hospital discounts, tariff differences, and amounts above the sum insured — accounts for ₹98.1 crore of the gap. The remaining ₹51.5 crore is the difference between the gross figure the patient submits and the net the insurer recognises before formal deduction coding even begins: room-rent capping, proportionate deductions, and the slice of the bill that falls outside the policy. The headline a company sees is the ₹320.6 crore. The ₹470.2 crore is what its workforce and the hospitals around it actually presented.

Three in four claims are paid; the rest sit in process or are denied#

Of the 74,339 claims in the window, the large majority have settled. The remainder split between claims still moving through the pipeline and a small denied tail.

The status mix carries two findings. The outstanding block — claims acknowledged but not yet settled — runs slightly more expensive per claim than the paid block (₹51,710 against ₹47,062), which is the natural signature of larger, more complex admissions taking longer to clear. The closed block, by contrast, is cheap: an average of ₹16,306, a third of the paid average. These are the small claims that resolve to little or nothing — minor events, withdrawn submissions, claims that fold into another.

The denied tail is the number worth sitting with. Repudiated claims are 3.4% of volume but carry almost no incurred cost, because a denied claim pays out nothing. The right way to read their weight is not on the incurred bar but on the claimed bar: that 3.4% of claims represents ₹16.6 crore of claimed amount the policy declined to pay at all. For the households behind those claims, the difference between a denial and a deduction is the difference between carrying part of a bill and carrying all of it.

The bill is built from a small number of very large claims#

The average claim incurred ₹43,129. The average is a poor description of the distribution. The median claim — the one in the middle, with as many above it as below — incurred ₹28,029. The mean sits 1.7 times higher than the median because a thin band of catastrophic admissions pulls it upward.

The concentration is sharper still when the claims are ranked by cost and the running total is tracked.

The costliest tenth of claims carries nearly half the bill. The cheapest half of claims — every admission below ₹28,029 — carries a small fraction of it. This is the structural fact that makes group-health cost volatile from one period to the next. A company's annual incurred figure is not a smooth function of how often its people fall ill. It is dominated by whether a handful of cardiac surgeries, cancer courses, or ICU stays land inside the policy year. The Top Categories by Incurred page and the Frequency vs Severity matrix later in this section take this apart claim category by claim category; the aggregate version is simply that most claims are small and most cost is large.

Cashless claims are 41% of volume but 66% of cost#

How a claim is settled turns out to be a strong predictor of how much it costs. Cashless claims — where the insurer pays the network hospital directly at discharge — are the minority by count but the majority by rupee.

The cashless claim costs 2.8 times the reimbursement claim on average. The reason is not the settlement mechanism itself. It is what each mechanism gets used for. Cashless requires a network hospital and a pre-authorisation, which makes it the route of choice for the planned, the major, and the expensive — the cardiac procedure, the cancer admission, the scheduled surgery large enough to be worth the paperwork. Reimbursement is the route for the smaller, more local, more urgent event, where the family pays first and claims later because the nearest hospital was not in network or the admission was too fast for pre-auth. The settlement split is, in effect, a severity split wearing different clothes. The claims-experience page later in this section examines what each route costs the household in time and friction; the cost asymmetry above is the reason the two routes are not interchangeable.

The parent layer is the largest single payer group in the policy#

The deeper pages of this section dissect the four relationship layers — employee, spouse, child, parent — in full. The aggregate teaser is the finding that frames them. The parent and parent-in-law layer is the single largest source of incurred cost in the book, ahead of the employees the policy is named for.

Two-thirds of claims are filed for someone other than the employee. The dependent layers together — spouse, child, parent — account for 66.5% of claims and 67.8% of incurred cost. The parent layer alone, at ₹118.2 crore, exceeds the employee's ₹103.1 crore on fewer claims, because the parent claim costs more: ₹53,981 against the employee's ₹41,432. The Family Claims page takes this multigenerational structure apart in full — the clinical mix of each layer, the gender skew within it, the way the parent share rises with company size. The aggregate point is simpler. A policy sold and reported as an employee benefit pays out, in rupee terms, mostly for the employee's household.

The largest employers carry both the most claims and the heaviest claims#

The book is concentrated in the enterprise tier — the largest companies, which both buy the broadest coverage and employ the most people.

The enterprise tier alone carries more than half the bill — ₹166.5 crore of the ₹320.6 crore. That follows from headcount. What is less obvious is the flat average. The cost of an individual claim barely moves across tiers: ₹41,904 at enterprise, ₹41,261 at SME, with the mid-market a few thousand rupees higher. The body that gets admitted to hospital costs roughly the same whether it belongs to a 5,000-person enterprise or a 200-person SME. The total bill differs because the number of bodies and the breadth of coverage differ — not because the per-claim biology does. The mid-market's slightly higher per-claim average is worth a footnote rather than a thesis: it reflects coverage and network mix more than any real difference in who falls ill.

What the claims book does not show — and why the loss ratio sits outside it#

This section reports incurred cost, not profitability. The two are often conflated. A company's loss ratio — incurred claims as a share of premium paid — is the number an insurer prices against and a broker negotiates around. It is also client-confidential at the account level, and this report does not publish it. The claims book holds the numerator of that ratio. The denominator, premium, is a commercial figure that belongs to each company's own renewal conversation.

What the aggregate claims book does establish is the cost-per-claim structure that any loss ratio is built from: an incurred average of ₹43,129, a median of ₹28,029, and a distribution whose top decile carries 44.8% of the weight. A company's experience in a given year is a draw from that distribution. Whether it lands above or below its premium line depends less on how healthy its people are on average than on whether the year delivered its share of the long tail.

The ₹320.6 crore is not a single bill. It is the sum of 74,339 separate admissions, most of them small, a thin band of them very large, filed mostly for people other than the employee whose policy carries them, settled mostly through a reimbursement queue that handles the cheap claims while the cashless desk handles the costly ones. The deeper pages of this section take each of those structural features apart. The shape they all share is the one this page established: a book whose weight sits in its tail, whose largest payer group is the elders on the policy, and whose ₹320.6 crore is the net that remains after ₹149.6 crore was shaved off the ₹470.2 crore that was actually asked for.