1. Gender and Age Trends: Maternity Claims Drive Higher Female Claim Rates; Males Show Rise in Lifestyle-Related Illnesses Women account for 60% of total claims, significantly outpacing men (40%), primarily due to maternity-related expenses.

• The 25-35 age group sees the highest claims, dominated by maternity coverage.
• Male employees aged 35-45 have the highest claims, reflecting a rise in lifestyle-related illnesses such as diabetes, cardiovascular diseases, and stress-related disorders.

Corporates are increasingly customizing age-specific health benefits, such as higher maternity coverage for female employees and wellness benefits for their workforce.

2. The Rising Cost of Healthcare: Tier 1 Cities Experience the Highest Claim Amounts

The average claim amount stands at INR 70,000 – 80,000, but regional insights highlight significant cost variations:City TierAvg. Claim Amount (INR)Key InsightTier 1 (Metro Cities)1 – 1.25 lakhHigh cost due to private hospital dominance and expensive medical procedures.Tier 270,000 – 80,000Balanced cost due to a mix of private and public healthcare facilities.Tier 340,000 – 60,000Lower medical expenses and reliance on government hospitals.Companies with operations in Tier 1 cities are opting for higher sum insured policies to protect employees from out-of-pocket expenses. Tier 2 and Tier 3 employers are exploring co-payment and deductible models to keep insurance premiums manageable while maintaining adequate coverage.3. Who Files the Most Claims? Physically Demanding Jobs See the Highest Claim RatesIndustries with the highest group health insurance claims typically involve physically strenuous roles, leading to frequent medical interventions:

• Manufacturing – Workplace injuries, exposure to hazardous materials, and repetitive strain disorders.
• Construction – High-risk environments with frequent accidents and fractures.
• Healthcare – Constant exposure to infections, burnout, and musculoskeletal strain from long shifts.
• Transportation & Logistics – Heavy lifting and prolonged working hours leading to back injuries and joint disorders.

Companies are implementing occupational health programs such as ergonomic training, injury prevention workshops, and onsite physiotherapy to reduce workplace-related health risks.4. New-Age Sectors: Tech-Driven Industries Are Embracing Group Health InsuranceIndustries with rising GHI adoption highlight a shift in employee benefits strategy, especially in sectors with young, health-conscious workforces:

• New-age startups – Attracting top talent with comprehensive healthcare benefits.
• E-commerce & online retail – Expanding workforce coverage due to rapid hiring and increasing awareness of insurance benefits.
• Fintech & IT – Growing demand for mental health, telemedicine, and preventive wellness benefits.

Customized, flexible health insurance plans are gaining traction, offering telehealth, mental wellness support, and stress management programs. Companies in tech sectors are bundling wellness incentives such as gym memberships and health-tracking apps into their policies to encourage proactive health management.5. Seasonal Claim Trends: Infectious Diseases Drive a Q2 Spike in ClaimsA sharp increase in claims occurs during Q2 (July – September), largely due to the surge in monsoon-related infectious diseases:

• Dengue, malaria, and typhoid dominate hospitalization claims.
• Employees in outdoor jobs (construction, logistics, field sales) are at higher risk.

Corporates are preparing for seasonal health risks by partnering with insurers to cover preventive vaccinations and health screenings before monsoon. Workplace hygiene initiatives (sanitization, mosquito control) are being reinforced to minimize infectious disease outbreaks.6. Employee Claim Frequency: 5-7% of Employees Account for Multiple Claims Annually

• 5-7% of employees file multiple claims annually, highlighting the impact of chronic illnesses and recurrent medical conditions.
• Cardiovascular diseases, respiratory disorders, and joint problems are among the leading causes of repeat claims.

Companies are enhancing preventive healthcare measures through regular health check-ups, workplace wellness programs, and chronic disease management interventions. Early detection programs are being integrated to identify high-risk employees and prevent serious medical conditions from escalating.7. Reimbursement vs. Cashless Claims: Cashless Claims Are More Common in Urban Areas

• Metro cities: 60% – 80% of claims are cashless, thanks to better hospital networks and insurer tie-ups.
• Non-metro cities: 40% – 55% cashless claim rates, leading to higher out-of-pocket expenses for employees.

Companies in non-metro areas are encouraging employees to use insurer-partnered hospitals to maximize cashless benefits. Insurers are also expanding their cashless hospital networks in Tier 2 and Tier 3 cities to increase adoption rates.

Sajja Praveen Chowdary, Director at Policybazaar for Business says “The evolving trends in group health insurance claims highlight the rising cost of medical care and the need for efficient claim processing. At Policybazaar for Business, we recognize that fair and timely settlements are essential for employee well-being and financial security. Our proactive claim review process has successfully overturned INR 2 crore in unfairly rejected or deducted claims, reinforcing our dedication to transparency and fairness. Through a combination of advanced technology, dedicated on-ground support across 203 cities, 24/7 claims assistance, and expert medical evaluations, we are simplifying the claims experience for employees. Our goal is to ensure that businesses and their workforce can rely on a system that prioritizes their needs, minimizes financial distress, and enhances trust in group health insurance.”