商业健康险赔付率仅40％？业界人士这样说→

Core Viewpoint - The development of commercial health insurance in China is under scrutiny due to low payout levels compared to premium growth, despite a significant increase in premium income and a projected annual total exceeding 1 trillion yuan in 2024 [3][4]. Premium Income and Growth - In 2024, China's commercial health insurance premium income reached 977.4 billion yuan, marking an 8.2% year-on-year increase, with a growth rate improvement of 3.8 percentage points compared to the previous year [3]. - By August 2025, premium income surpassed 759.9 billion yuan, with expectations for the total to exceed 1 trillion yuan by year-end [3]. Payout Analysis - In 2024, commercial health insurance payouts were approximately 403.8 billion yuan, resulting in a simple payout ratio of around 40%, significantly lower than the 70%-85% range seen in developed countries [3][4]. - The payout ratio is considered misleading as it does not accurately reflect the insurance's compensation capabilities, particularly due to the long-term nature of critical illness insurance, which constitutes about 50% of the premium income [4][5]. True Payout Rates - A study published in "Insurance Theory and Practice" indicated that the overall payout ratio for medical insurance in 2023 was 73.42%, up from 64.18% in 2022, with a payout ratio of approximately 75% when excluding critical illness insurance [6]. - Different types of medical insurance exhibit varying payout ratios, with long-term medical insurance ranging from 55% to 80%, while short-term personal health insurance has a payout ratio of 50% to 70% for individual policies and 100% to 120% for group policies [6][7]. Group Health Insurance - Group health insurance, primarily covering corporate and government clients, generated a premium income of 128.1 billion yuan in 2023, indicating a significant market share [7][8]. - The payout ratios for group health insurance, particularly for critical illness and corporate supplemental medical insurance, are consistently higher than those for personal short-term health insurance, leading to a dual challenge of high payout expenses and operational losses [8]. Profitability Challenges - The insurance industry's profitability is constrained by high comprehensive cost ratios, which include management and sales costs, rather than solely by payout ratios [9]. - The high cost of acquiring healthy individuals and the accumulation of insured individuals with pre-existing conditions contribute to a cycle of increased sales costs and reduced payout capabilities, impacting the overall insurance function [9]. Future Directions - The research suggests that the core of commercial health insurance development lies in maintaining its protective attributes and innovating medical insurance products to enhance actual cost-sharing capabilities and precision in covering medical expenses [10].