According to industry experts, claims in the ₹2–5 lakh and above-₹5 lakh categories are increasing, driven largely by cardiac conditions, cancer treatment, kidney disease and orthopaedic procedures.
Shift towards larger claims
“A huge chunk of the claims we see today are still in that ₹1–2 lakh range, mostly for standard surgeries. But the ₹2–5 lakh bracket is catching up fast,” said Sarita Joshi, Head of Life & Health Insurance of Probus.
According to Joshi, rising hospital overheads and room rents are pushing even routine treatments into higher cost bands. She added that claims above ₹5 lakh are no longer limited to rare medical emergencies, as advanced procedures are becoming increasingly common across hospitals.
Data shared by Abhishek Poddar, Co-founder, Plum, showed that 12.7% of hospitalisation claims currently fall in the ₹1–2 lakh bracket, while 6.5% are in the ₹2–5 lakh range.
Claims above ₹5 lakh account for 1.3% of cases.
While these large-ticket claims form a relatively small share by volume, insurers said they account for a rising portion of total payouts.
Anshul Mittal, Joint President and Appointed Actuary, HDFC ERGO General Insurance, said claims below ₹1 lakh still dominate by count, but their share has been declining year-on-year because of rising treatment costs and medical inflation.
“At the upper end, claims above ₹5 lakh continue to form a small proportion of overall hospitalisations in count but form a significant proportion in total amount and the share is increasing fast,” Mittal said.
Critical illnesses driving payouts
Insurers said critical illnesses continue to be the largest contributors to claim costs.
Mittal said cancer, heart-related diseases and chronic kidney disease are among the biggest cost drivers in India’s health insurance segment today.
“Together, in these three treatments, 50% of annual medical treatment cost is above ₹5 lakh today,” he said.
Joshi said cardiac procedures now typically cost between ₹3 lakh and ₹8 lakh, while cancer treatment expenses can exceed ₹10 lakh depending on the stage of disease and type of treatment involved.
She also pointed to rising claims linked to musculoskeletal conditions such as spine surgeries and knee replacements, driven by sedentary lifestyles and an ageing population.
Plum’s data showed that cardiac patients recorded median treatment costs of ₹1.18 lakh, while the top 10% of claims reached ₹5.57 lakh. For cancer treatments, the median cost stood at ₹2.31 lakh, with the top-end claims touching ₹7.9 lakh.
Musculoskeletal procedures showed median costs of ₹1.45 lakh, while chronic kidney disease and renal treatments recorded median expenses of ₹1.52 lakh.
Maternity claims remained relatively lower in value but high in frequency. Plum said maternity-related admissions stood at 184.7 patients per 1,000, with median claim costs of ₹75,000.
Concerns over cover exhaustion
Experts also highlighted a growing trend of policyholders exhausting their insurance coverage during a single treatment cycle.
“A ₹10 lakh bill used to be an outlier, but now it’s quite common in metro hospitals,” Joshi said.
She noted that many patients are finding their base health cover inadequate for prolonged critical illness treatment, forcing them to pay for follow-up care out of pocket unless they have top-up coverage.
Plum said the incidence of claims above ₹7.5 lakh has increased 22% in recent years, with cardiac ailments and cancer accounting for 38% of such claims. Other contributors include gastrointestinal surgeries, renal treatments such as dialysis and orthopaedic procedures.
Mittal said the increasing use of advanced procedures, including robotic surgeries, is also contributing to rising claim sizes and higher insurance requirements.
The trend is prompting insurers to focus more on higher sum insured products, restoration benefits and top-up plans as healthcare costs continue to rise faster than overall inflation.
