Data & Data Checks

Premium Files

Premium Register Versus Financials
Year Premium_Financials Premium_Data Absolute_Difference Percentage_Difference
2022 3,571,431,630 3,570,190,105 1,241,525 3.0%
2023 4,333,193,661 4,333,157,903 35,758 0.0%
2024 4,772,501,408 4,772,501,408 0 0.0%
2025 2,690,327,228 2,690,327,228 0 0.0%
TOTAL 15,367,453,927 15,366,176,644 1,277,283 1.0%

Claim Files

Claim Bordereaux Listing Versus Financials
Year Claims_Financials Claims_Data Absolute_Variance Percentage_Variance
2023 3,260,043,054 3,257,441,736 2,601,318 0.1%
2024 3,874,459,939 3,864,281,084 10,178,855 0.3%
2025 2,211,322,203 2,179,585,800 31,736,403 1.4%
TOTAL 9,345,825,196 9,301,308,620 44,516,576 0.5%
Claim Bordereaux Register Versus Claims Dump Register
refined_source sum_amount_dump pct_dump sum_amount_bordereaux pct_bordereaux n_claims
Bordereaux Only 0 0.0% 636,532,768 6.9% 76,970
Both 8,637,918,139 94.7% 8,637,918,139 93.2% 910,607
Dump Only 472,585,227 5.2% 0 0.0% 67,542
Mismatch of Amount 9,770,226 0.1% -6,432,347 -0.1% 5,207
Unclassified 0 0.0% 0 0.0% 6,387
Total 9,120,273,592 100.0% 9,268,018,560 100.0% 1,066,713

Dump Only and Mismatch of Amount have been considered to be outstanding claims.

Whole portfolio Profitability

📊 Incurred Loss Ratio Trends

  • Incurred loss ratio decreased from 102.2% in 2023 to 90.6% in 2024.
  • Incurred loss ratio decreased from 90.6% in 2024 to 80.6% in 2025.
  • Current loss ratio in 2025 is 80.6%, which is 5.6 percentage points above the target of 75.0%.

Loss Ratio By Underwriting Year

Exposure Analysis

📊 Exposure Profile Observations

📈 Lives Insured Growth
  • Total lives insured increased from 109,840 in 2023 to 152,379 in 2024.
  • Total lives insured decreased from 152,379 in 2024 to 132,645 in 2025.
🧑‍🤝‍🧑 Gender Mix Summary
  • No significant change noted across all comparisons.
👨‍👩‍👧‍👦 Family Size Trends
  • No significant change noted across all comparisons.
📊 Age Band Changes
  • No significant change noted across all comparisons.

Detailed Profitability Analysis

Scheme Level Analysis

Distribution of Schemes

Scheme Portfolio Breakdown by Claim Ratio Band
Scheme Count
Lives Insured
Person Years
Premium Earned
Claim Count
Total Claim Amount
Loss Year Ratio Band Number % Number % Number % Number % Number % Number %
2023 <50% 234 36 53,651 25 40,212 24 408,749,208 14 9,434 3 138,637,730 5
2024 <50% 302 42 75,457 28 50,680 28 525,233,738 13 11,159 4 179,478,286 5
2025 <50% 322 52 21,710 14 8,833 14 304,550,235 16 7,692 6 69,501,830 5
2023 >50%, <75% 89 14 33,806 16 26,790 16 693,529,969 23 45,297 16 467,097,763 15
2024 >50%, <75% 151 21 55,064 21 39,090 22 1,068,595,438 27 74,471 24 700,740,801 20
2025 >50%, <75% 135 22 69,527 43 27,782 43 757,930,954 39 41,099 31 470,106,083 31
2023 >75%, <100% 81 12 58,438 27 47,459 28 1,134,360,356 38 94,237 32 1,000,488,093 33
2024 >75%, <100% 113 16 74,343 28 49,841 27 1,423,503,889 36 125,698 40 1,233,858,881 36
2025 >75%, <100% 83 13 33,662 21 13,583 21 412,138,292 21 33,751 26 348,038,490 23
2023 >100% 244 38 66,741 31 54,819 32 755,147,608 25 141,958 49 1,413,180,248 47
2024 >100% 147 21 61,349 23 42,109 23 891,578,889 23 99,504 32 1,328,060,810 39
2025 >100% 85 14 35,133 22 14,888 23 452,653,852 23 49,130 37 614,325,957 41
2023 TOTAL 648 100 212,636 100 169,280 100 2,991,787,141 100 290,926 100 3,019,403,834 100
2024 TOTAL 713 100 266,213 100 181,720 100 3,908,911,955 100 310,832 100 3,442,138,778 100
2025 TOTAL 625 100 160,032 100 65,086 100 1,927,273,333 100 131,672 100 1,501,972,360 100

✅ 4 Wins

  • In 2025, Lives Insured % in the '>50%, <75%' band increased by 22 points compared to 2024.
  • In 2025, Person Years % in the '>50%, <75%' band increased by 21 points compared to 2024.
  • In 2024, Scheme Count % in the '>100%' band decreased by 17 points compared to 2023.
  • In 2024, Claim Count % in the '>100%' band decreased by 17 points compared to 2023.

⚠️ 3 Losses

  • In 2025, Lives Insured % in the '<50%' band decreased by 14 points compared to 2024.
  • In 2025, Person Years % in the '<50%' band decreased by 14 points compared to 2024.
  • In 2024, Claim Count % in the '>75%, <100%' band increased by 8 points compared to 2023.

📌 Recommendations

  • Review schemes in high loss bands.
  • Incentivize low-loss ratio performance.
  • Engage brokers on emerging trends.

Poorly performing schemes

Schemes in Ratio Band >100% with Lives > 1000 - 2025
Scheme Name Earned Premium Lives Insured Claim Ratio Remaining Months
SAMA SOURCE KENYA LIMITED 72,826,685 4,625 140.6% 7
U.S. EMBASSY 47,622,336 5,388 148.3% Expired
KENYA ELECTRICITY TRANSMISSION COMPAN… 44,336,052 2,101 122.5% 1
KENYA NATIONAL BUREAU OF STATISTICS 42,637,566 1,728 103.5% 2
CHRIST IS THE ANSWER MINISTRIES (CITAM) 32,685,571 2,998 104% Expired
CHESTER COMMUNITY PRODUCT 19,705,491 3,347 190.5% Expired
INDEPENDENT POLICING OVERSIGHT AUTHORITY 18,867,517 1,107 134.4% 1
USAID- KENYA 15,362,495 1,705 221.7% Expired
BRAEBURN SCHOOLS LIMITED 14,262,459 1,616 114.1% 5
Schemes in Ratio Band >75%, <100% with Lives > 1000 - 2025
Scheme Name Earned Premium Lives Insured Claim Ratio Remaining Months
AGL KENYA LTD 34,517,908 3,594 78.2% Expired
NATIONAL DROUGHT MANAGEMENT AUTHORITY. 23,361,744 2,967 83.4% 9
HIGHLANDS DRINKS LIMITED 13,551,421 2,501 87.8% Expired
GULF AFRICAN BANK LIMITED 28,792,824 2,134 99.3% Expired
NORTHERN RANGELANDS TRUST 12,203,057 2,105 75.3% Expired
COASTAL BOTTLERS LTD. 7,363,646 1,470 90.7% Expired
NATIONAL WATER HARVESTING AND STORAGE… 21,149,821 1,410 76% Expired
MOMBASA WATER SUPPLY AND SANITATION C… 14,699,451 1,364 76.4% Expired
KENYA ORDNANCE FACTORIES CORPORATION … 11,417,798 1,315 89.8% Expired

Channel Level Analysis

Channel Portfolio Breakdown by Claim Ratio Band
Channels Count
Lives Insured
Person Years
Premium Earned
Claim Count
Total Claim Amount
Loss Year Ratio Band Number % Number % Number % Number % Number % Number %
2023 <50% 58 35 46,954 22 34,876 21 113,778,075 3 7,976 3 187,539,689 5
2024 <50% 82 45 63,754 24 43,152 24 212,362,165 5 10,653 3 302,858,760 8
2025 <50% 103 65 64,643 40 25,534 39 499,223,304 22 24,766 16 383,334,488 21
2023 >50%, <75% 29 17 7,871 4 6,108 4 207,606,769 6 11,806 4 131,246,536 4
2024 >50%, <75% 40 22 84,753 32 60,717 33 1,573,786,837 36 116,855 34 1,080,472,851 27
2025 >50%, <75% 32 20 42,530 27 17,803 27 740,694,287 32 40,287 26 450,525,413 24
2023 >75%, <100% 29 17 68,852 32 56,415 33 1,252,710,093 38 94,608 30 999,637,767 29
2024 >75%, <100% 32 17 97,751 37 64,835 36 2,229,149,381 51 185,948 53 2,101,144,228 53
2025 >75%, <100% 12 8 41,985 26 17,224 26 879,909,133 38 68,783 44 796,397,946 43
2023 >100% 52 31 88,959 42 71,881 42 1,733,743,034 52 204,484 64 2,116,544,807 62
2024 >100% 29 16 19,955 7 13,016 7 319,458,868 7 35,142 10 477,215,125 12
2025 >100% 12 8 10,874 7 4,525 7 190,288,365 8 21,123 14 219,389,555 12
2023 TOTAL 168 100 212,636 100 169,280 100 3,307,837,971 100 318,874 100 3,434,968,799 100
2024 TOTAL 183 100 266,213 100 181,720 100 4,334,757,250 100 348,598 100 3,961,690,964 100
2025 TOTAL 159 100 160,032 100 65,086 100 2,310,115,088 100 154,959 100 1,849,647,402 100

✅ 3 Wins

  • In 2024, EP Per Year % in the '>100%' band decreased by 45 points compared to 2023.
  • In 2024, Claim Count % in the '>100%' band decreased by 54 points compared to 2023.
  • In 2024, Total Amount % in the '>100%' band decreased by 50 points compared to 2023.

⚠️ 3 Losses

  • In 2024, EP Per Year % in the '>75%, <100%' band increased by 13 points compared to 2023.
  • In 2024, Claim Count % in the '>75%, <100%' band increased by 23 points compared to 2023.
  • In 2024, Total Amount % in the '>75%, <100%' band increased by 24 points compared to 2023.

📌 Recommendations

  • Review Channels in high loss bands.
  • Incentivize low-loss ratio performance.
  • Engage brokers on emerging trends.

Poorly performing Channels

Channels in Ratio Band >100% with Lives > 500 - 2025
Channel
Lives Insured
2023
2024
2025
Earned Premium Claim Ratio Earned Premium Claim Ratio Earned Premium Claim Ratio
SEDGWICK 3630 11,593,859 98.3% 75,830,048 123.8% 61,484,017 112.2%
ZAMARA 5242 127,247,752 139.4% 37,023,083 91% 93,725,785 114.4%
PELICAN 898 NA NA% 5,642,456 97.6% 21,677,326 107.3%
Channels in Ratio Band >75%, <100% with Lives > 500 - 2025
Channel
Lives Insured
2023
2024
2025
Earned Premium Claim Ratio Earned Premium Claim Ratio Earned Premium Claim Ratio
DIRECT 32771 1,179,490,072 118.4% 1,694,208,171 96.5% 730,901,489 91%
AMS 2885 2,652,396 53.7% 47,783,953 90.2% 39,737,903 82.3%
THANAWALLA 2096 5,355,972 94.8% 33,173,730 115.8% 29,084,195 99.1%
MINET 1777 78,615,807 83.2% 35,193,970 82.3% 18,267,867 82.1%
TEE VEE 576 11,502,141 102.3% 15,244,908 108.3% 9,296,743 75.6%

Line of Business Level Analysis

LOB Breakdown by Claim Ratio Band
Lives Insured
Person Years
Premium Earned
Claim Count
Total Claim Amount
LOB Loss Year Claim Ratio Ratio Band Number % Number % Number % Number % Number %
ALL LOBs 2023 102.24 >100% 212,636 100 169,280 100 3,376,872,241 100 320,811 100 3,452,479,092 100
ALL LOBs 2024 90.60 >75%, <100% 266,213 100 181,720 100 4,392,224,533 100 350,029 100 3,979,399,148 100
ALL LOBs 2025 80.57 >75%, <100% 160,032 100 65,086 100 2,339,208,840 100 158,102 100 1,884,810,757 100
COMMUNITY 2023 94.00 >75%, <100% 5,838 3 3,447 2 137,025,982 4 633 0 128,996,918 4
COMMUNITY 2024 301.00 >100% 7,129 3 5,123 3 66,812,915 2 937 0 200,951,744 5
COMMUNITY 2025 234.00 >100% 3,688 2 1,434 2 46,796,552 2 474 0 109,597,688 6
CORPORATE 2023 105.00 >100% 172,091 81 140,240 83 3,017,155,989 89 310,367 97 3,173,608,343 92
CORPORATE 2024 90.00 >75%, <100% 206,066 77 139,933 77 3,995,383,618 91 339,614 97 3,587,445,980 90
CORPORATE 2025 80.00 >75%, <100% 116,780 73 48,123 74 2,093,040,042 89 153,157 97 1,664,550,700 88
RETAIL 2023 28.00 <50% 33,380 16 24,639 15 176,763,901 5 951 0 49,399,916 1
RETAIL 2024 43.00 <50% 51,673 19 35,781 20 197,084,912 4 1,587 0 85,161,615 2
RETAIL 2025 57.00 >50%, <75% 37,808 24 14,774 23 157,907,605 7 3,455 2 90,434,809 5
SME 2023 219.00 >100% 1,327 1 954 1 45,926,368 1 8,860 3 100,473,915 3
SME 2024 80.00 >75%, <100% 1,345 1 883 0 132,943,088 3 7,891 2 105,839,809 3
SME 2025 49.00 <50% 1,756 1 755 1 41,464,641 2 1,016 1 20,227,560 1

📊 Line of Business Observations

📈 Claim Ratio Growth
2023 vs 2024:
  • ALL LOBs: Claim ratio decreased by 11.6% from 102.2% to 90.6%.
  • COMMUNITY: Claim ratio increased by 207.0% from 94.0% to 301.0%.
  • CORPORATE: Claim ratio decreased by 15.0% from 105.0% to 90.0%.
  • RETAIL: Claim ratio increased by 15.0% from 28.0% to 43.0%.
  • SME: Claim ratio decreased by 139.0% from 219.0% to 80.0%.

2024 vs 2025:
  • ALL LOBs: Claim ratio decreased by 10.0% from 90.6% to 80.6%.
  • COMMUNITY: Claim ratio decreased by 67.0% from 301.0% to 234.0%.
  • CORPORATE: Claim ratio decreased by 10.0% from 90.0% to 80.0%.
  • RETAIL: Claim ratio increased by 14.0% from 43.0% to 57.0%.
  • RETAIL: Proportion of lives increased by 5.0%.
  • SME: Claim ratio decreased by 31.0% from 80.0% to 49.0%.

Claim Analysis

Maternity Claims Summary by Age Band and Year

📊 Total Maternity Claim Cost (KES)

📈 Maternity Claim Incidence Rate

💰 Average Cost per Maternity Visit

Chronics

Service Provider Analysis

Service Providers Payout Distribution

Number of Facilities Accounting for Payout Thresholds by Year
Year 50% 75% 100%
2023 13 52 2,231
2024 12 50 2,239
2025 11 39 1,574
🔍 Provider Payout Concentration Insights: Over-concentrated if total payments make up less than 30%
  • 2023: Over-concentration: only 13 providers (0.6%) accounted for 50% of payouts. Still concentrated: just 52 providers (2.3%) accounted for 75% of payouts.
  • 2024: Over-concentration: only 12 providers (0.5%) accounted for 50% of payouts. Still concentrated: just 50 providers (2.2%) accounted for 75% of payouts.
  • 2025: Over-concentration: only 11 providers (0.7%) accounted for 50% of payouts. Still concentrated: just 39 providers (2.5%) accounted for 75% of payouts.

Total Payouts

Top 10 Providers in 2024 with Amount, Share, and Rank Across Years
2023
2024
2025
Provider Amount (KES) % Rank Amount (KES) % Rank Amount (KES) % Rank
THE AGA KHAN UNIVERSITY HOSPITAL 372,684,817 10.8% 1 365,496,622 9.2% 1 193,824,821 10.3% 1
AVENUE HEALTHCARE LTD 215,398,633 6.2% 2 260,981,229 6.6% 2 127,934,733 6.8% 2
EQUITY AFIA LIMITED 123,801,870 3.6% 6 211,695,245 5.3% 3 109,997,652 5.8% 3
SOCIAL SERVICE LEAGUE M.P. SHAH HOSPITAL 161,904,043 4.7% 4 204,246,914 5.1% 4 96,710,505 5.1% 4
KENYA HOSPITAL ASSOCIATION 167,738,236 4.9% 3 202,292,383 5.1% 5 93,857,299 5.0% 5
GERTRUDES CHILDRENS HOSPITAL 141,854,891 4.1% 5 150,292,761 3.8% 6 84,889,592 4.5% 6
THE AGA KHAN HOSPITAL KISUMU 107,043,723 3.1% 7 140,677,472 3.5% 7 66,641,627 3.5% 7
THE AGA KHAN HOSPITAL MOMBASA 101,019,772 2.9% 8 120,056,265 3.0% 8 46,004,592 2.4% 8
PANDYA MEMORIAL HOSPITAL 80,623,911 2.3% 9 97,577,292 2.5% 9 33,821,999 1.8% 13
OPTICA 79,473,563 2.3% 10 89,442,074 2.2% 10 44,186,235 2.3% 10

🏥 Insights on Top 10 Providers by Payout (2023–2025)

🏆 THE AGA KHAN UNIVERSITY HOSPITAL ranked 1st in 2023, 2024, 2025.

  • EQUITY AFIA LIMITED moved from rank 6 to 3 in 2024 (improved).
  • PANDYA MEMORIAL HOSPITAL dropped out of top 10 in 2025.
  • THE MATER HOSPITAL entered top 10 in 2025 at position 9.

Average cost per visit

🏥 Priority 1 Providers – Average Cost by Benefit (2023–2025)
Provider
Overall Avg Cost
In-Patient Avg Cost
Out-Patient Avg Cost
Provider 2023 2024 2025 2023 2024 2025 2023 2024 2025
AVENUE HEALTHCARE LTD 17,266 15,776 14,708 47,451 46,581 42,497 5,427 5,651 5,937
EQUITY AFIA LIMITED 5,850 6,031 5,966 10,274 9,113 8,418 3,585 3,517 4,068
GERTRUDES CHILDRENS HOSPITAL 16,227 14,221 14,107 46,491 39,072 41,419 5,819 6,284 7,241
INDIA HOSPITAL 78,990 66,987 74,459 205,840 193,849 173,393 14,817 15,642 22,710
KENYA HOSPITAL ASSOCIATION 26,981 39,825 20,465 78,439 96,364 77,654 8,199 8,477 8,150
OPTICA 12,226 12,972 11,856 15,346 15,020 14,908 10,136 11,194 6,370
PANDYA MEMORIAL HOSPITAL 38,364 33,140 39,955 105,294 118,254 108,795 6,114 6,453 5,492
SOCIAL SERVICE LEAGUE M.P. SHAH HOSPITAL 61,642 45,132 49,537 87,155 113,454 105,937 6,198 6,593 6,499
THE AGA KHAN HOSPITAL KISUMU 50,877 30,859 29,389 81,164 97,669 88,495 6,601 6,743 6,263
THE AGA KHAN HOSPITAL MOMBASA 23,599 27,770 31,365 80,285 87,475 104,669 5,842 5,746 4,921
THE AGA KHAN UNIVERSITY HOSPITAL 31,998 30,967 33,735 128,489 117,984 116,463 6,983 7,120 6,925
📋 Top 10 Priority 2 Providers – Average Cost by Benefit (2023–2025)
Provider
Overall Avg Cost
In-Patient Avg Cost
Out-Patient Avg Cost
Provider 2023 2024 2025 2023 2024 2025 2023 2024 2025
AAR HEALTHCARE KENYA LIMITED 7,779 7,477 7,651 13,645 14,050 15,828 5,163 5,137 5,834
AAR HOSPITAL LIMITED 29,857 27,122 31,982 74,114 107,136 111,228 6,169 5,646 6,362
BRISTOL PARK HOSPITAL LIMITED 17,365 36,080 20,764 54,423 62,955 70,130 4,845 4,664 4,880
COPTIC HOSPITAL 33,387 32,880 34,931 111,522 112,118 102,441 4,219 4,959 5,150
MEDINA MEDICARE HOSPITAL LIMITED 32,036 19,738 15,035 78,813 52,750 47,460 5,329 5,666 6,982
METROPOLITAN HOSPITAL NAIROBI 16,335 24,836 16,427 55,593 56,325 52,580 4,651 5,066 5,215
MOMBASA HOSPITAL ASSOCIATION 69,580 45,356 104,461 132,692 146,798 202,071 6,468 6,978 6,851
PREMIER HOSPITAL LIMITED 23,368 15,482 19,195 60,591 32,389 33,033 5,056 5,030 5,358
THE MATER HOSPITAL 19,231 27,121 43,497 73,378 71,541 118,047 5,656 5,950 6,870
THE NAIROBI WOMENS HOSPITAL 22,553 14,807 40,697 43,908 47,923 56,142 3,997 3,708 4,213

Average cost insights:

💡 Insights on Average Claim Cost Changes by Priority Group

📌 Priority 1 Providers
2023–2024:
  • SOCIAL SERVICE LEAGUE M.P. SHAH HOSPITAL increased by 28% from KES 21,989 to KES 28,141.
  • KENYA HOSPITAL ASSOCIATION increased by 23.6% from KES 19,016 to KES 23,495.
2024–2025:
  • No significant changes noted.
📌 Priority 2 Providers
2023–2024:
  • CHIROMO LANE MEDICAL CENTRE increased by 24.4% from KES 20,963 to KES 26,085.
  • AAR HOSPITAL LIMITED increased by 30.9% from KES 13,790 to KES 18,050.
  • VALLEY HOSPITAL increased by 26.8% from KES 13,178 to KES 16,708.
2024–2025:
  • NAIROBI WEST HOSPITAL LIMITED increased by 22.9% from KES 124,456 to KES 152,899.
  • MOMBASA HOSPITAL ASSOCIATION increased by 90.8% from KES 50,803 to KES 96,953.

🔎 Investigate

The following providers recorded a year-on-year increase in average cost greater than 30% in at least one period:

  • AAR HOSPITAL LIMITED
  • MOMBASA HOSPITAL ASSOCIATION

Ailment Analysis

Threshold Summary Table

Number of Ailments Covering Key Payout Percentiles
Loss_Year 50% 75% 100%
2023 15 48 292
2024 17 49 293
2025 18 51 282
🔍 Ailment Payout Concentration Insights: Over-concentrated if total payments make up less than 30%
  • 2023: Over-concentration: only 15 ailments (5.1%) accounted for 50% of payouts. Still concentrated: just 48 ailments (16.4%) accounted for 75% of payouts.
  • 2024: Over-concentration: only 17 ailments (5.8%) accounted for 50% of payouts. Still concentrated: just 49 ailments (16.7%) accounted for 75% of payouts.
  • 2025: Over-concentration: only 18 ailments (6.4%) accounted for 50% of payouts. Still concentrated: just 51 ailments (18.1%) accounted for 75% of payouts.

Top AIlments By Payout based on year 2024

Top 10 Ailments by Total Payout (Based on 2024 Rankings)
2023
2024
2025
Ailment Amount % Rank Amount % Rank Amount % Rank
Other diseases of upper respiratory tract 236,350,275 6.8% 1 267,352,601 6.7% 1 122,790,738 6.5% 1
 Diseases of esophagus, stomach and duodenum 184,202,442 5.3% 2 207,870,929 5.2% 2 88,637,244 4.7% 3
 Diseases of oral cavity and salivary glands 167,024,930 4.8% 3 199,603,878 5% 3 90,447,720 4.8% 2
 Disorders of ocular muscles, binocular movement, accommodation and refraction 150,001,945 4.3% 4 150,000,439 3.8% 4 68,705,908 3.6% 5
 Acute upper respiratory infections 142,552,196 4.1% 5 145,705,240 3.7% 5 62,393,462 3.3% 7
 Hypertensive diseases 117,758,582 3.4% 6 144,011,786 3.6% 6 73,014,454 3.9% 4
 General symptoms and signs 108,091,465 3.1% 7 119,636,593 3% 7 68,223,802 3.6% 6
 Influenza and pneumonia 83,504,196 2.4% 9 116,741,878 2.9% 8 49,022,612 2.6% 8
 Persons encountering health services in circumstances related to reproduction 106,072,808 3.1% 8 103,934,792 2.6% 9 40,979,093 2.2% 10
 Benign neoplasms, except benign neuroendocrine tumors 72,094,515 2.1% 10 95,989,692 2.4% 10 43,328,420 2.3% 9

🩺 Insights on Top 10 Ailments by Payout (2023–2025)

🏆 Other diseases of upper respiratory tract ranked 1st in 2023, 2024, 2025.

  •  Influenza and pneumonia entered top 10 in 2025 at position 8.
  •  Persons encountering health services for examinations dropped out of top 10 in 2025.
  •  Persons encountering health services in circumstances related to reproduction dropped out of top 10 in 2025.
  •  Diabetes mellitus entered top 10 in 2025 at position 10.

Average cost Analysis for the Ailments

🩺 Priority 1 Ailments - Average Cost (Ordered by 2024 Average Cost)
Average Cost
Ailment 2023 2024 2025
 Persons encountering health services in circumstances related to reproduction 36,665 27,279 22,405
 Benign neoplasms, except benign neuroendocrine tumors 22,938 25,300 27,954
 Disorders of refraction and accommodation 16,923 18,284 18,870
 Diabetes mellitus 15,541 16,143 19,219
 Influenza and pneumonia 13,549 14,298 16,462
 Disorders of ocular muscles, binocular movement, accommodation and refraction 14,240 13,783 13,643
 Diseases of oral cavity and salivary glands 11,128 11,450 11,951
 Hypertensive diseases 10,221 11,109 11,564
 Diseases of esophagus, stomach and duodenum 10,003 10,013 10,221
 Urolithiasis 8,627 9,130 9,627
 Intestinal infectious diseases 8,961 8,742 9,066
Chronic lower respiratory diseases 8,352 8,510 8,833
 General symptoms and signs 7,834 8,063 8,281
Other diseases of upper respiratory tract 6,504 6,720 6,525
 Acute upper respiratory infections 5,981 5,751 6,436
 Persons encountering health services for examinations 4,479 5,544 8,814
📋 Top 10 Priority 2 Ailments - Average Cost (Ordered by 2024 Average Cost)
Average Cost
Ailment 2023 2024 2025
 Ischemic heart diseases 97,379 115,928 78,145
 Disorders of gallbladder, biliary tract and pancreas 107,446 95,786 78,501
 Hernia 94,929 90,398 75,294
 Assault 84,531 68,540 88,708
 Birth trauma 28,270 35,799 31,142
In situ neoplasms 23,440 31,057 19,704
 Diseases of male genital organs 40,221 28,881 23,900
 Osteoarthritis 25,551 26,332 28,015
 Metabolic disorders 16,450 22,012 21,001
 Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals 19,341 21,045 20,056

💡 Insights on Average Claim Cost Changes by Ailment Priority Group

📌 Priority 1 Ailments
2023–2024:
  •  Persons encountering health services in circumstances related to reproduction decreased by 25.6% from KES 36,665 to KES 27,279.
  •  Persons encountering health services for examinations increased by 23.8% from KES 4,479 to KES 5,544.
2024–2025:
  •  Persons encountering health services for examinations increased by 59% from KES 5,544 to KES 8,814.
📌 Priority 2 Ailments
2023–2024:
  •  Birth trauma increased by 26.6% from KES 28,270 to KES 35,799.
  • In situ neoplasms increased by 32.5% from KES 23,440 to KES 31,057.
  •  Diseases of male genital organs decreased by 28.2% from KES 40,221 to KES 28,881.
  •  Metabolic disorders increased by 33.8% from KES 16,450 to KES 22,012.
2024–2025:
  •  Ischemic heart diseases decreased by 32.6% from KES 115,928 to KES 78,145.
  •  Assault increased by 29.4% from KES 68,540 to KES 88,708.
  • In situ neoplasms decreased by 36.6% from KES 31,057 to KES 19,704.

Claim Distribution By Age Profile

Mid Year Claims Paid Analysis

Reconciliation

📊 Mid-Year Claims vs Financials Reconciliation
Loss_Year Paid_bordereaux Financials Difference Percent_Diff
2023 1,549,373,539 1,551,715,914 -2,342,375 -0.2%
2024 1,757,578,149 1,755,814,743 1,763,406 0.1%
2025 2,179,585,800 2,211,322,203 -31,736,403 -1.4%

Reserve Utilization Summary

This table shows reserve usage against actual claim payments for each payment year (2023–2025), broken down by service year. The final row highlights the (Over)/Under Utilization after accounting for the reserve.

Reserve Utilization Summary by Payment Year
Loss_Year_Group 2023 2024 2025
2022 and Prior 500,279,353 11,244,532 6,520,527
2023 1,049,053,737 402,814,589 20,041,277
2024 0 1,109,108,648 563,346,312
2025 0 0 1,589,631,988
NA 40,449 234,410,380 45,696
Total Paid 1,549,373,539 1,757,578,149 2,179,585,800
Current-Year Paid 1,049,053,737 1,109,108,648 1,589,631,988
Reserve Utilized 500,319,802 648,469,500 589,953,812
Reserves 181,869,142 310,062,089 234,082,334
(Over)/Under Utilization -318,450,660 -338,407,411 -355,871,478

Top Providers in the Half Year

2023
2024
2025
Service Provider Amount % Rank Amount % Rank Amount % Rank
THE AGA KHAN UNIVERSITY HOSPITAL 176,445,898 11.4% 1 175,277,635 10% 1 206,359,584 9.5% 1
AVENUE HEALTHCARE LTD 103,795,029 6.7% 2 120,581,951 6.9% 2 125,813,927 5.8% 2
EQUITY AFIA LIMITED 50,803,964 3.3% 6 69,382,487 3.9% 6 107,679,786 4.9% 3
KENYA HOSPITAL ASSOCIATION 76,223,195 4.9% 3 86,205,060 4.9% 3 99,380,311 4.6% 4
SOCIAL SERVICE LEAGUE M.P. SHAH HOSPITAL 76,027,578 4.9% 4 77,300,582 4.4% 4 97,676,515 4.5% 5
THE AGA KHAN HOSPITAL KISUMU 46,779,571 3% 8 62,546,833 3.6% 7 72,785,717 3.3% 6
GERTRUDES CHILDRENS HOSPITAL 68,753,011 4.4% 5 73,428,310 4.2% 5 72,366,489 3.3% 7
THE AGA KHAN HOSPITAL MOMBASA 48,012,200 3.1% 7 41,288,472 2.3% 8 49,508,588 2.3% 8
THE MATER HOSPITAL 37,592,825 2.4% 9 27,598,683 1.6% 12 44,119,994 2% 9
OPTICA 30,998,328 2% 11 39,720,595 2.3% 10 43,329,524 2% 10

Production

Channel
2023
2024
2025
Amount % Rank Amount % Rank Amount % Rank
DIRECT 1,725,412,950 39.8 1 1,732,416,872 36.3 1 668,620,471 24.9 1
I&M 381,856,155 8.8 2 562,075,410 11.8 2 507,929,030 18.9 2
CSI 356,390,907 8.2 3 464,269,598 9.7 3 294,211,366 10.9 3
D&G 189,084,906 4.4 5 196,747,323 4.1 4 166,451,450 6.2 5
CHESTER 201,904,122 4.7 4 176,858,095 3.7 5 72,863,047 2.7 6
SEDGWICK 11,232,834 0.3 32 124,638,058 2.6 6 33,469,793 1.2 12
BTB 125,856,332 2.9 7 95,487,821 2.0 7 51,840,884 1.9 10
AMS 3,116,845 0.1 87 78,251,049 1.6 8 72,755,913 2.7 7
DTB 62,691,166 1.4 10 76,243,876 1.6 9 54,335,581 2.0 9
MTN 65,816,063 1.5 9 76,116,999 1.6 10 7,041,557 0.3 33

Areas of improvement

🚧 Areas That Are Pending

  • Utilization of Member Benefits – Awaiting deeper analysis on limits versus usage patterns.
  • Reconciliation of Premium Using Underwriting Years – Requires reconciling written premium to the year it relates to.
  • Insights on Pricing – To be developed based on claim trends and segment performance at a family level.