What the Policy Actually Pays For

The most expensive category on Loop's broker book in the latest twelve months — musculoskeletal injury and fracture, at ₹34.4 Cr of incurred expense — is also one of the rarest. It is the seventh most common category by claim volume and the first by rupees. The pattern repeats down the table. The conditions that drive the spend are not the conditions the policy sees most often. They are the ones that, when they arrive, arrive large.

This page ranks the same 74,339 claims that the Top Categories by Frequency page ranks, on a different axis: total incurred rupees rather than claim count. The two rankings disagree, and the disagreement is the finding. The frequency page measures how often the policy is used. This page measures where the money goes. A health policy is bought to absorb the second, and the second is governed by a small number of high-severity categories that a claim-count view actively hides.

Eight categories absorb two-thirds of the bill#

The first finding is concentration. The incurred bill is not spread evenly across the hundreds of conditions the policy covers. It collapses onto a handful.

The top three categories each clear ₹33 Cr and sit within ₹0.8 Cr of one another. Below them the bars fall away. By the eighth category the policy has accounted for two rupees in every three it pays. The remaining third is the long tail — eye and cataract, neurological, skin, endocrine, and the dozens of smaller lines that together never match what cardiac alone costs.

The most expensive categories are the rarest#

The clearest way to see why the rupee ranking and the count ranking disagree is to put them side by side. The gap between a category's frequency rank and its incurred rank is a severity signal.

Cardiac and circulatory disease is the most extreme case. It is the eleventh most common category — 3.3% of claims — and the fourth most expensive, at 8.4% of spend. The average cardiac admission costs ₹1.10 lakh, nearly triple the average infection or maternity admission. Cancer behaves similarly, climbing from frequency rank ten to incurred rank eight. These are the low-frequency, high-severity categories: the policy sees them rarely and pays heavily when it does.

The inverse case is starker still. General health services — routine consultations, check-ups, minor encounters — is the single most-filed category, 15.7% of all claims. It is sixteenth by spend, 1.1% of incurred, at an average of ₹2,910 a claim. It tops the frequency page and all but vanishes from this one. The Frequency vs Severity matrix plots that divergence as a single picture.

The catastrophic categories run through the parent layer#

The companion page on who the policy pays for established that parents and parents-in-law are the single largest relationship layer, at 36.9% of incurred. This page shows why. The catastrophic categories — the ones that set the rupee ranking — concentrate sharply in the parent generation.

Two-thirds of the cardiac bill and well over half the cancer bill come off the parent layer. The musculoskeletal line splits — employee injury (workplace and commute trauma) competes with parent fracture (post-fall hip and femur) for the top of the category. Maternity is, by definition, the spouse layer's: 76% of maternity incurred attaches to spouses, 23% to female employees.

The per-claim severity within these categories also runs highest at the parent layer. A parent cardiac admission averages ₹1.16 lakh against ₹1.01 lakh for an employee; a parent fracture averages ₹1.09 lakh against ₹84,000 for an employee. The parent generation arrives with the most advanced presentation of each condition, and the most expensive — which is the case the Parent Claims page makes in full.

Maternity loses the most between claimed and incurred#

Incurred is not claimed. The gap between what hospitals bill and what insurers pay varies by category, and the variation is itself a finding.

Maternity carries the highest deduction rate of any major category — more than a third of the billed amount is not paid by the insurer. Maternity benefits in most Indian group policies carry explicit sub-limits (a fixed cap for normal delivery, a higher cap for caesarean), and those caps bite. A delivery billed above the sub-limit is paid only to the cap; the remainder is the household's. Cardiac and cancer also deduct heavily, near a third, reflecting non-payable consumables and the room-rent and proportionate-deduction clauses that apply most to expensive admissions.

The catastrophic spend concentrates at the largest employers#

Catastrophic categories sit disproportionately at the Enterprise tier, which reflects how parental coverage is sold. Enterprise plans carry parents by default; smaller plans often do not.

Of cardiac incurred, 57% comes off Enterprise-tier accounts; of cancer incurred, 58%. The mid-market tiers split most of the rest, and the SME tier — where parental coverage is frequently excluded — carries 2% of each. The catastrophic bill is, structurally, an Enterprise-tier bill, because the layer that drives it (the parent) is a layer that only the larger employers underwrite.

The bill is concentrated, and the concentration is the opening#

The shape of the incurred bill is the same shape every catastrophic-risk pool takes. A few high-severity categories — cardiac, cancer, serious fracture — drive a disproportionate share of the spend, while the high-frequency claims that fill the count report cost comparatively little. Two-thirds of ₹320.6 Cr lands on eight categories, and most of that eight runs through the parent generation and the metabolic disease that precedes it by twenty years.