13个精算师·2025-07-10 15:16Core Insights - The medical insurance claims in 2024 exceeded 86 billion, with an average annual growth rate of 21% over the past decade [1][12][87] - The report highlights significant cases of high claims, including five cases with total payouts exceeding 3 million and eight individuals with over 100 claims [1][21] - The trend of "one-stop" settlement for hospital discharges is gaining traction, with major companies like China Life and Ping An reporting direct payments exceeding 4 billion [1][48] - The age groups most affected by medical claims are 30-50 years and 0-17 years, with a higher incidence of claims among males in the child category [1][55][60] Medical Claims Overview - Medical claims have shown rapid growth, with total payouts reaching 405.2 billion in 2024, a sevenfold increase compared to ten years ago [12][87] - The report includes data from 68 life insurance companies, with 60 companies disclosing medical claims totaling over 86 billion [12][13] - Major insurers like Renmin Health reported over 20 billion in claims, while Ping An Life and Ping An Health reported over 12 billion [13][14] Claim Characteristics - The medical insurance claims are characterized by high frequency and low average payout, with nearly 80% of companies reporting average claims below 3,000 [19][34] - The report emphasizes that while average payouts may seem low, the high frequency of claims reflects the nature of medical insurance as a reimbursement product [19][20] High Payout Cases - Notable cases include individuals receiving over 3 million in claims, with companies like Fude Life, Xinhua Insurance, and AIA reporting multiple high-claim cases [26][30] - The report details that some medical insurance products have guaranteed renewal periods, allowing for cumulative payouts to exceed initial coverage limits [26] Special Drug Payments - In 2024, Ping An Health paid over 19 billion for special drugs, while Taibao Health reported a maximum payout of 1.2 million for CAR-T therapy [36][44] - The introduction of commercial health insurance innovation drug directories in the 2025 medical insurance catalog is expected to enhance coverage for previously excluded innovative drugs [40][41] One-Stop Settlement - The trend of one-stop settlement for medical claims is being adopted by several insurers, with 11 companies reporting direct payment amounts exceeding 12 billion in 2024 [50][51] - Companies like China Life and Ping An Life have reported direct payments exceeding 4 billion, indicating a shift towards more efficient claim processing [51][49] Age and Gender Distribution - The report indicates that the most common age groups for medical claims are 30-50 years and 0-17 years, with a notable prevalence of claims among males in the child category [55][60] - Female claims are generally higher in adult age groups, reflecting greater health awareness and insurance purchasing behavior among women [62][66] Claim Causes - The majority of medical claims are due to diseases, with respiratory infections being the most common reason for claims [72][76] - In contrast, accidental claims are primarily related to animal bites and sprains, highlighting the different nature of claims in medical insurance [81][82]