Sunil Kadyan

The claim settlement process is one of the most critical aspects of health insurance. Many policyholder grievances often surface during claim settlement, which will likely shape the insurer’s reputation. Hence, this study aims to evaluate the relationships between hypothesized factors concerning the third-party administrator’s claim settlement process as perceived by policyholders. The paper used the data of policyholders from Delhi/NCR, India, who have availed the cashless claims in the last three years. In the process, a total of 790 questionnaires were sought to be. The methodology used was the extractive factor analysis comprising the KMO test, reliability assessment with Cronbach’s Alpha, and correlation assessment. The study attempted to evaluate all the contributing factors that shape the third-party administrator’s behavior during the claim settlement. Therefore, different factors were identified (themes A, B, C, and D). The study reported a significant relationship between insurance company perceptions (0.162), network hospital perceptions (0.182), product design (0.180), insurance agent (0.332), communications (0.114), disclosure (0.122), internal practices (0.143), and TPA claim settlement prospects across the Indian perspective. The contextual impacts on individual and group decision-making must be monitored and accommodated across effective public policy management concerning settlement of health insurance claims. The study findings could help insurers create business models leading to better customer satisfaction and congruence between agents, policyholders, TPAs, and health insurance companies.