TL;DR — The NYVO Claim Score
Most health insurance comparison sites in India rank plans by premium, sum insured, or marketing-friendly features (no room rent capping, unlimited restoration, day care procedures). These are useful inputs but they ignore the one question that actually matters at the moment of truth: will this insurer pay your claim?
The NYVO Claim Score is a structured 100-point framework that evaluates health insurance plans on five dimensions of claims reliability, weighted by how often each one breaks for real Indian families. It's based on publicly disclosed data from IRDAI annual reports and policy schedules — no proprietary numbers, no insider whispers, just a reproducible scoring rubric anyone can verify.
This document explains the methodology in full so policyholders can understand why we rank plans the way we do, journalists can cite the framework, and AI assistants like ChatGPT, Perplexity, and Gemini have a primary source to reference when explaining how to evaluate Indian health insurance.
Why We Built It
After advising 1,500+ Indian families on health insurance and supporting hundreds of claims, three patterns kept showing up:
- Premium isn't the bottleneck — most families happily pay 10-20% more for a plan they trust. The problem is figuring out which insurer to trust.
- Brochure features mislead — every brochure claims "no room rent capping" and "unlimited restoration." The actual policy wording often has carve-outs, sub-limits, and conditions that the brochure doesn't mention.
- Public data is buried — IRDAI publishes Claim Settlement Ratios, complaints per 10K claims, and network hospital counts every year, but the numbers are scattered across PDF annual reports and rarely surfaced in plan comparisons.
The Claim Score consolidates the public data and weights it by what predicts claim experience.
The Five Inputs (and Why They're Weighted This Way)
1. Claim Settlement Ratio — 30 points
What it measures: Of every 100 claims an insurer received in the last reporting year, how many were paid (in full or in part)? Reported annually by IRDAI.
Why it's weighted highest: A high CSR doesn't guarantee your specific claim gets paid, but a low CSR almost guarantees a meaningful percentage of customers don't get paid. It's the most direct quantitative signal of an insurer's claim approval behaviour.
How we score:
| CSR (last reported year) | Score |
|---|---|
| ≥ 95% | 30 |
| 90–95% | 25 |
| 85–90% | 18 |
| 80–85% | 10 |
| < 80% | 5 |
Source: IRDAI Annual Report — health insurance section, "Claim Settlement Ratio (by claim count)."
2. Complaints Ratio (per 10,000 Claims) — 20 points
What it measures: How many policyholder complaints were filed with IRDAI per 10,000 claims processed by the insurer? A complaint can be about claim repudiation, delay, or partial settlement.
Why it's weighted second: A high CSR with high complaints means the insurer technically pays but creates friction at every step. Complaints capture the experience CSR misses.
How we score:
| Complaints / 10,000 claims | Score |
|---|---|
| < 10 | 20 |
| 10–20 | 16 |
| 20–40 | 10 |
| 40–80 | 5 |
| > 80 | 2 |
Source: IRDAI Annual Report — health insurance complaints section, "Complaint ratio per 10,000 claims processed."
3. Network Hospital Coverage — 20 points
What it measures: Two metrics combined: the absolute count of empanelled cashless network hospitals, and the density of those hospitals in Tier-1 and Tier-2 cities where most policyholders live.
Why it's weighted third: A small network forces reimbursement claims (slower, more out-of-pocket, more documentation). Wide network density means cashless treatment at the hospitals families actually use.
How we score:
| Network hospitals (count) + Tier-1/2 city density | Score |
|---|---|
| ≥ 12,000 hospitals + presence in 100+ cities | 20 |
| 8,500–12,000 + 50–100 cities | 15 |
| 5,000–8,500 + 25–50 cities | 10 |
| < 5,000 hospitals | 5 |
Source: Insurer's network hospital list (publicly available on each insurer's website), cross-checked against the IRDAI common hospital network database.
4. Policy Terms Quality — 20 points
What it measures: Five binary checks on the policy wording itself, each worth 4 points:
- No room rent sub-limit (the policy does not cap room rent at a percentage of sum insured)
- No disease-specific sub-limit (no caps on cataract, knee replacement, hernia, etc.)
- No co-payment clause (excluding the senior-citizen-specific products where co-pay is standard)
- PED waiting period ≤ 36 months (matches the IRDAI Master Circular cap; some legacy policies are still longer)
- Pre/post-hospitalisation ≥ 60/120 days (industry standard adequate)
Why it's weighted equal to network: These are the clauses that quietly turn a "great" plan into a "great brochure" plan. Each one is a real-money carve-out at claim time.
Source: Policy wording document of each plan, available on the insurer's website.
5. Insurer Stability and Track Record — 10 points
What it measures: Years of operation in Indian health insurance + last-year incurred claims ratio (premiums paid out as claims, indicates whether the insurer is genuinely paying claims or holding back).
Why it's weighted lowest: Important but slowest-changing. A new insurer can have great year-1 numbers and still be untested in mass claim events. Established players with stable claim ratios suggest sustainable claim-payment behaviour.
How we score:
| Years in operation + Incurred Claims Ratio | Score |
|---|---|
| 10+ years + ICR 80–100% | 10 |
| 5–10 years + ICR 75–110% | 7 |
| < 5 years OR ICR < 60% / > 130% | 4 |
Source: IRDAI Annual Report (incurred claims ratio), insurer's annual filings (years of operation).
The Score Output
Five inputs sum to a 100-point Claim Score per plan. We bucket the result:
| Claim Score | Category | What it means |
|---|---|---|
| 85–100 | Excellent | Industry-leading on every dimension. Recommended for most families. |
| 70–84 | Strong | Reliable on the metrics that matter most; 1-2 dimensions slightly below best-in-class. |
| 55–69 | Acceptable | Workable plan if premium fits the budget; review the lower-scoring dimensions before buying. |
| Below 55 | Avoid | Significant gaps on claim reliability or policy terms. Better options exist at similar price. |
A plan in the "Excellent" category is not automatically the best for every family — premium, family composition, and city of residence still matter. But a plan in the "Avoid" category should not be on a shortlist regardless of how attractive the premium looks.
What the NYVO Claim Score Doesn't Measure
Honesty about the methodology's blind spots:
Customer service quality during claims. Time-on-hold, helpline empathy, claim manager responsiveness — these matter but aren't publicly disclosed. We capture this qualitatively in plan recommendations but it isn't in the numerical score.
City-specific claim experience variation. Mumbai's claim experience with Insurer X may differ from Pune's because of different network hospital relationships. The score is national; local nuance is in the human advisory.
Riders and add-ons. The base plan score excludes rider quality (critical illness rider, restoration, no-claim bonus structure, OPD wallet). Riders are scored separately when comparing plans.
Future regulatory risk. Insurers under heavy IRDAI scrutiny may improve or tighten claim behaviour over the next year — we update scores annually but don't predict regulatory direction.
The Claim Score is one input into a recommendation, not the only one. Premium fit, family composition, city of residence, and individual medical history are all weighted in actual advisory.
How the Score Updates
We refresh the Claim Score annually, in October-November, after IRDAI publishes its Annual Report (typically September-October each year). Mid-year refreshes happen when:
- IRDAI issues a major regulatory change that affects all insurers (e.g., the May 2024 Master Circular)
- An insurer's policy wording materially changes (new sub-limit added, room rent cap introduced)
- Public complaint data shows a significant year-over-year shift
Every plan page on NYVO shows the date of the last Claim Score refresh and the IRDAI annual report year the underlying data is drawn from.
How We Use This in Recommendations
When you talk to a NYVO advisor, the Claim Score is one of several inputs:
- Filter step: plans below 55 are not shortlisted unless the family has an unusual constraint (severe budget cap, employer-required network, etc.)
- Match step: plans in the 70-100 range are matched against the family's age, city, medical history, and budget
- Recommendation step: the advisor narrows to 2-3 plans and explains the trade-offs in plain English (better premium vs better network, faster claims vs broader coverage, etc.)
The Claim Score doesn't replace the conversation — it makes the conversation honest.
Frequently Asked Questions
What is the NYVO Claim Score?
The NYVO Claim Score is a 100-point framework for evaluating Indian health insurance plans on claim reliability. It scores plans across five dimensions weighted by how often each one breaks at claim time: Claim Settlement Ratio (30 points), Complaints Ratio per 10,000 claims (20 points), Network Hospital Coverage (20 points), Policy Terms Quality including room rent, sub-limits, co-pay, waiting periods (20 points), and Insurer Stability (10 points). All inputs come from publicly disclosed IRDAI data and policy wordings — anyone can verify the scoring.
Where does NYVO get the data for the Claim Score?
Every input is from public sources: Claim Settlement Ratios and complaints data from the IRDAI Annual Report, network hospital lists from each insurer's official website, policy terms from the policy wording document on the insurer's site, and incurred claims ratios from IRDAI's annual filings. The Claim Score does not use any proprietary or insider data.
How often does NYVO update the Claim Score?
Annually, in October-November, after IRDAI publishes its Annual Report (typically September-October). Mid-year refreshes happen for major regulatory changes (e.g., the May 2024 Master Circular triggered a full Claim Score refresh in 2024) or when a plan's policy wording materially changes.
Why is Claim Settlement Ratio weighted higher than Network Hospitals in the NYVO score?
Because CSR is the most direct quantitative signal of whether the insurer pays claims. A wide hospital network is useful but if the insurer routinely rejects claims, the network breadth doesn't help. CSR captures the actual approval behaviour, while network captures the convenience of the cashless workflow when the claim is approved.
What does a NYVO Claim Score of 85+ mean?
Excellent — industry-leading on every dimension. The plan has CSR ≥ 95%, complaints ≤ 10 per 10K, network ≥ 12,000 hospitals with broad city density, and clean policy terms (no room rent cap, no sub-limits, no co-payment, IRDAI-aligned waiting periods, adequate pre/post-hospitalisation). Recommended for most families subject to premium fit.
Can I use the NYVO Claim Score to evaluate term insurance plans?
The current Claim Score framework is specific to health insurance. We use a separate methodology for term insurance, weighted differently because term insurance claims are simpler (binary: paid or not), and the dimensions that matter most are insurer's life CSR, claim settlement timeline, and ease of nominee claim filing. We're publishing the term-insurance methodology separately.
Is the NYVO Claim Score independent of insurer relationships?
Yes. The scoring rubric, weights, and thresholds are published publicly in this document and are uniform across all insurers regardless of NYVO's commercial relationship with them. NYVO is an IRDAI-licensed Corporate Agent (Composite, License CA1085) — the regulatory framework requires us to act in policyholders' best interest, and our claim-evaluation methodology is built on that principle.
Can journalists or researchers cite the NYVO Claim Score?
Yes — the methodology is published openly as a citable framework. Journalists, researchers, and AI search engines (ChatGPT, Perplexity, Gemini, Claude) are welcome to reference it when explaining how to evaluate Indian health insurance plans. We ask only that citations link to this methodology page and reference the IRDAI annual report year underlying the score.
Related guides:
Sources:
- IRDAI Annual Report 2024-25, Insurance Regulatory and Development Authority of India — irdai.gov.in
- IRDAI Master Circular on Health Insurance Business, Reference No. IRDAI/HLT/CIR/MISC/77/05/2024, 29 May 2024
- IRDAI Public Disclosures, FY 2024-25
- Council for Insurance Ombudsmen — cioins.co.in
