从头部险企健康险理赔“结构”，看实际保障力度被低估

Core Insights - The article discusses the current state and challenges of commercial health insurance in China, highlighting the impact of policy and technology on the industry's growth and the perception of its value [1][2]. Group 1: Business Growth and Challenges - In 2025, the total premium for commercial health insurance reached 997.3 billion yuan, with a year-on-year growth of 2.04%, falling short of the expected trillion-yuan mark [2][13]. - The decline in health insurance premiums from life insurance companies, which saw a 5.9% drop in December 2025, has contributed to the overall negative growth in the sector [2][14]. - Life insurance companies reported a slight decrease in health insurance premiums for the entire year of 2025, totaling 769.9 billion yuan, down 0.41% from the previous year [2][14]. Group 2: Claims and Payouts - Despite the challenges faced by life insurance companies, the value of health insurance claims remains significant, with "medical + critical illness" claims accounting for about 80% of total payouts among leading insurers [5][16]. - For instance, China Life reported over 788 billion yuan in health insurance claims, representing 78.5% of its total claims in 2025 [6][17]. - The trend shows that medical insurance continues to have the highest number of claims, while critical illness insurance has the highest payout amounts [7][18]. Group 3: Underestimated Actual Payout Rates - There is a prevailing belief that the payout rate for commercial health insurance in China is low, around 40%, which is significantly below the 70%-85% range seen in developed countries [8][19]. - Recent analyses suggest that this perception is misleading, as the payout rate for medical insurance, excluding critical illness insurance, is approximately 75% [8][19]. - The actual payout rates for long-term medical insurance range from 55% to 80%, while short-term health insurance shows a payout rate of 50% to 70% for individual policies and 100% to 120% for group policies [8][19]. Group 4: Strategies for Growth and Risk Management - The industry needs to address the dual challenge of scaling growth while managing risks effectively to unlock the full value of health insurance [9][20]. - Expanding coverage for individuals with pre-existing conditions and chronic diseases is seen as a viable strategy to tap into new market segments [9][20]. - Insurers are encouraged to innovate products tailored to specific demographics, such as high-end consumers and the elderly, to better meet diverse needs [10][21].