What the Policy Is Claimed For Most Often

Of the 74,339 hospital claims Loop's broker book absorbed in the latest twelve months, the category claimed for most often — once a large administrative bucket is set aside — is infection and fever, at 11.7% of all claims and an average incurred cost of ₹38,674. The most frequent claims on a group-health policy are, almost without exception, the high-volume, lower-severity events of ordinary living: viral fevers, deliveries, stomach infections, kidney and urinary complaints, cataracts. They are common because the bodies on the policy are mostly working-age and mostly well. This page ranks the policy by how often each category is claimed. Its mirror — the Top Categories by Incurred page — ranks the same book by money, and the two rankings are not the same ranking. That gap is the entire point of reading them together.

Infection and fever leads the clinical frequency ranking; the top of the raw table is an administrative artefact#

The raw frequency table is headed by a category that is not a disease.

The top row needs setting aside before the clinical reading begins. "General health services" is an ICD Z-code bucket — administrative and follow-up encounters rather than acute illness. In this book it is dominated by persons encountering health services in other circumstances: implant and stent removals, day-care procedures, examinations, post-treatment follow-ups. At an average of ₹2,910 a claim against a book-wide average of ₹43,129, it is the cheapest category on the policy by an order of magnitude, and it carries 15.7% of the claim volume while accounting for 1.1% of the rupees. It is a real operational load — a sixth of every claim filed is administrative paperwork on a procedure that already happened — but it is not a clinical signal, and the frequency ranking that matters for health begins at row two.

Read clinically, the order is infection and fever first, maternity second, kidney and urinary complaints third, gastrointestinal fourth, eye and cataract fifth. None of these is a surprise. All five are the routine claim mix of a covered population that is mostly young, mostly working, and mostly healthy. What the volume conceals is cost, and cost is where the ranking starts to come apart.

The most frequent half of claims is not the most expensive half#

The five most frequent clinical-and-administrative categories account for 50.6% of every claim filed. They account for 37.0% of every rupee spent. The policy's frequency table and its cost table are pulling in different directions, and the cleanest way to see it is to line up each category's rank on both.

Two categories carry the divergence. Musculoskeletal injury is the seventh most frequent claim and the most expensive in aggregate — uncommon as an event, but at ₹89,455 a claim it concentrates a large share of the book's rupees into a relatively small share of its admissions. Cardiac sits eleventh by frequency and fourth by money, on the highest per-claim cost of any category at ₹1.10 lakh. The categories where the two ranks agree — infection at 2 and 2, maternity at 3 and 3, gastrointestinal at 5 and 5 — are the ones whose cost is simply a function of how often they happen. The categories where the ranks diverge are the ones where severity, not frequency, drives the bill.

The frequency leader changes with every layer of the household#

The policy's overall frequency ranking is an average across four very different populations. Split by who the claim is filed for, the most-claimed category changes in every layer — and the change tracks the biology of each life stage.

The employee files most often for the infections and minor illness of an active working body. The spouse layer is dominated by a single event — more than one in three spouse claims is a maternity admission, the most concentrated frequency signal anywhere in the book. The child layer is paediatric infectious disease: viral fevers and the respiratory admissions of early childhood. The parent layer's most frequent claim is the cataract — the routine surgical signature of an ageing eye — sitting ahead of the kidney, cancer, and cardiac admissions that make the parent layer the most expensive in the policy.

The maternity concentration in the spouse layer is worth holding onto, because it is the one place where a single category dominates a layer's entire claim profile. It also explains a structural feature of the frequency ranking: maternity reaches third place book-wide almost entirely on the strength of one relationship layer. Strip the spouse layer out and maternity falls well down the table. The Maternity and Delivery page takes that one line apart in full, and the Family Claims page sets out how the four relationship layers carry the book between them.

Maternity rises and the administrative bucket falls as the company gets smaller#

The frequency mix shifts with the size of the employer — not randomly, but along two clean gradients.

Two gradients run in opposite directions. Maternity and infection both climb as the employer gets smaller — from 8.8% to 14.3% for maternity, 10.7% to 15.7% for infection, moving from Enterprise to SME. Smaller employers run younger, leaner workforces whose claim mix is dominated by the everyday events of working-age life; their policies also more often exclude the parent layer, removing the older, costlier admissions that dilute these shares at the Enterprise tier. The administrative "general health services" bucket runs the other way, concentrated heavily at the Enterprise tier (22.4%) and thinning to 6.2% at SME — a reporting and procedural-coding pattern that follows the larger employers' more complex, parent-inclusive books rather than a clinical one.

Infection, gastrointestinal, and respiratory claims skew male; maternity is the only female-dominated frequent category#

Across the high-frequency clinical categories, the gender split sits close to the policy's underlying composition — with one definitional exception.

The clinical frequency categories — infection, gastrointestinal, respiratory, kidney — all sit between 38% and 41% female. That is close to the policy's own gender composition rather than a finding about the categories themselves; the employee base skews male, and the everyday-illness categories inherit that skew. Maternity is the lone deviation, female by definition. The signal here is what is absent: the high-frequency categories carry no surprising gender concentration. The gendered patterns in this book live in the rarer, costlier categories — cardiac, fracture, oncology — which is to say, on the next page.

What the frequency ranking is, and is not, telling you#

The frequency table is the most honest portrait of what living on a group-health policy is actually like. It is mostly fevers and deliveries and stomach infections and cataracts — the ordinary, survivable events of working-age and early-retirement life, claimed often precisely because they are common and rarely catastrophic. The administrative bucket at the top is the policy's paperwork, not its pathology. The clinical leaders below it are the texture of routine health.

What the table cannot tell you is where the money goes, and it would be a mistake to read it as if it could. The categories that head the frequency list — infection, maternity, gastrointestinal — are mid-cost at worst. The categories that head the cost list — cardiac, musculoskeletal injury, cancer — sit in the lower half of the frequency table, rare events that each carry a large bill. The Frequency vs Severity matrix later in this section plots both axes at once. A policy is claimed for the common thing and bankrupted by the rare one.