📘 Executive Summary

This report, prepared by the Actuarial Team, presents an analysis of the current performance trends within the GA Medical Portfolio. It highlights the portfolio’s profitability, key movements in claims experience, and proposes actionable recommendations aimed at improving efficiency and overall profitability.

The portfolio’s incurred loss ratio has shown a consistent improvement, declining from 100% in 2023 to 74.9% as at September 2025. This year-to-date ratio is, however, subject to revision following the incorporation of outstanding claims from Mtiba, Pre-Auths and Smart.

There has been a notable improvement in scheme performance, with the number of schemes within the desired loss ratio range increasing by 40, accompanied by a decline in loss-making schemes, an indication of the effectiveness of recent pricing interventions.

Overall portfolio membership has reduced by 33%, driven by declines of 38% and 30% in the Corporate and Community lines of business, respectively. Conversely, the SME band Retail segments registered marginal increases in covered lives. The improvement in loss ratios for the Corporate and Community lines may partly be attributed to the exit of previously loss-making schemes.

The Direct line of business recorded a 37% reduction in premium income. We recommend further assessment to establish whether this decline stems from migration from direct to intermediary channels, shedding off of poorly performing accounts or total exits from GA due to service delivery concerns.

Provider concentration remains a key observation, with only 12 providers accounting for 50% and 41 providers accounting for 75% of total claims paid in 2025. This level of concentration presents an opportunity to introduce capitation or cost-regulation models, particularly for high-volume providers, to leverage economies of scale and enhance cost control.

We recommend further investigation of the following providers due to significant increase in average cost of treatment: KENYA HOSPITAL ASSOCIATION, PANDYA MEMORIAL HOSPITAL, AAR HOSPITAL LIMITED and MEDINA MEDICARE HOSPITAL LIMITED. The report includes an interactive table which enables the user to view average cost statistics for each provider selected.

A similar pattern is observed across ailments, where 18 of 285 ailments account for 50% and 53 ailments account for 75% of total claim amounts. A targeted review and cost-effective management of these high-cost ailments is recommended to sustain profitability improvements.

Lastly, the medical reserves continue to exhibit year-on-year overutilization, rising from 208 million in 2024 to 390 million in 2025. It is therefore recommended that reserves be strengthened to ensure adequacy in meeting emerging claims obligations.

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 0.00%
2023 4,333,193,661 4,333,157,903 35,758 0.00%
2024 4,772,501,408 4,772,501,408 0 0.00%
2025 3,590,452,937 3,590,452,937 0 0.00%
TOTAL 16,267,579,636 16,266,302,353 1,277,283 0.00%

Claim Files

Claim Bordereaux Listing Versus Financials
Year Claims_Financials Claims_Data Absolute_Variance Percentage_Variance
2023 3,260,043,054 3,248,938,809 11,104,245 0.3%
2024 3,874,459,939 3,864,281,084 10,178,855 0.3%
2025 3,192,002,006 3,171,366,305 20,635,701 0.6%
TOTAL 10,326,504,999 10,284,586,198 41,918,801 0.4%
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% 672,954,369 6.6% 81,377
Both 9,592,500,396 95.7% 9,592,500,396 93.5% 1,004,049
Dump Only 425,615,203 4.2% 0 0.0% 64,297
Mismatch of Amount 3,777,454 0.0% -8,177,255 -0.1% 5,564
Unclassified 0 0.0% 0 0.0% 6,463
Total 10,021,893,053 100.0% 10,257,277,510 100.0% 1,161,750

📘 Reconciliation Summary – Bordereaux vs Dump Register

There are notable variances:

  • Bordereaux Only: KES 470.77 million (1.2%) — claims recorded in the Bordereaux but not in the Dump.
  • Dump Only: KES 0.00 million (0%) — claims appearing in the Dump but missing from the Bordereaux.
  • Mismatch (Bordereaux): KES 470.77 million (1.2%) — differences in amounts recorded in Bordereaux.

Totals used: Dump = KES 20,043.79 million (49.4%); Bordereaux = KES 20,514.56 million (50.6%) (combined = KES 40,558.34 million).

For reconciliation purposes, the ‘Dump Only’ and ‘Mismatch of Amount’ categories have been treated as outstanding claims pending further review.

Whole portfolio Profitability

📊 Incurred Loss Ratio Trends

  • Incurred loss ratio decreased from 100.4% in 2023 to 90.0% in 2024.
  • Incurred loss ratio decreased from 90.0% in 2024 to 74.9% in 2025.
  • Current loss ratio in 2025 is 74.9%, which is 0.1 percentage points below the target of 75.0%.

Exposure Analysis

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Exposure insights

📊 Exposure Profile Observations

📈 Lives Insured Growth
  • Total lives insured increased from 109,866 in 2023 to 152,527 in 2024.
  • Total lives insured decreased from 152,527 in 2024 to 143,437 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% 256 38 18,665 8 13,614 8 151,073,169 11 3,624 1 35,698,623 1
2024 <50% 237 31 15,219 5 9,315 5 124,321,965 5 2,914 1 30,382,012 1
2025 <50% 268 40 19,401 10 11,086 11 294,172,990 14 6,896 3 59,744,392 2
2023 >50%, <75% 74 11 13,076 6 9,507 5 173,548,419 12 13,285 4 112,301,080 3
2024 >50%, <75% 98 13 12,152 4 7,698 4 167,132,931 7 9,768 3 103,237,257 3
2025 >50%, <75% 107 16 21,314 11 12,147 12 597,789,129 28 36,697 16 357,130,701 13
2023 >75%, <100% 56 8 20,812 9 15,533 9 314,992,879 22 27,078 9 267,323,372 8
2024 >75%, <100% 96 13 54,196 19 34,638 18 740,316,869 31 72,215 21 677,499,585 17
2025 >75%, <100% 80 12 29,232 15 15,883 15 501,797,586 24 47,489 20 457,153,566 16
2023 >100% 296 43 170,753 76 138,038 78 796,929,420 55 261,201 86 2,935,489,855 88
2024 >100% 323 43 201,912 71 143,869 74 1,372,143,041 57 264,420 76 3,294,378,025 80
2025 >100% 214 32 118,957 63 63,381 62 718,315,934 34 141,532 61 1,953,025,171 69
2023 TOTAL 682 100 223,306 100 176,692 100 1,436,543,888 100 305,188 100 3,350,812,930 100
2024 TOTAL 754 100 283,479 100 195,520 100 2,403,914,806 100 349,317 100 4,105,496,879 100
2025 TOTAL 669 100 188,904 100 102,497 100 2,112,075,640 100 232,614 100 2,827,053,830 100

✅ 2 Wins

  • In 2025, EP Per Year % in the '>50%, <75%' band increased by 21 points compared to 2024.
  • In 2025, EP Per Year % in the '>100%' band decreased by 23 points compared to 2024.

⚠️ 7 Losses

  • In 2024, Scheme Count % in the '<50%' band decreased by 7 points compared to 2023.
  • In 2024, EP Per Year % in the '<50%' band decreased by 6 points compared to 2023.
  • In 2024, Lives Insured % in the '>75%, <100%' band increased by 10 points compared to 2023.
  • In 2024, Person Years % in the '>75%, <100%' band increased by 9 points compared to 2023.
  • In 2024, EP Per Year % in the '>75%, <100%' band increased by 9 points compared to 2023.
  • In 2024, Claim Count % in the '>75%, <100%' band increased by 12 points compared to 2023.
  • In 2024, Total Amount % in the '>75%, <100%' band increased by 9 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
SAMA SOURCE KENYA LIMITED 112,360,128 4,768 110.8%
KENYA ELECTRICITY TRANSMISSION COMPAN… 70,298,430 4,085 109.8%
USAID- KENYA 24,398,640 1,706 201.9%
INDEPENDENT POLICING OVERSIGHT AUTHORITY 19,911,737 1,113 144.5%
DANDG INSURANCE BROKERS LTD 418,872 17,912 453.6%
BAPA INSURANCE BROKERS LIMITED 192,591 17,912 147.9%
Schemes in Ratio Band >75%, <100% with Lives > 1000 - 2025
Scheme Name Earned Premium Lives Insured Claim Ratio
FREEDOM AIRLINE EXPRESS LIMITED 3,942,170 17,912 85%
KENYA MEDICAL RESEARCH INSTITUTE 285,149,995 6,429 82.4%
KENYA MARINE AND FISHERIES RESEARCH I… 89,777,070 4,296 75.5%
NATIONAL DROUGHT MANAGEMENT AUTHORITY. 44,152,084 3,013 84.5%
CHRIST IS THE ANSWER MINISTRIES (CITAM) 32,685,571 2,998 98.2%
HIGHLANDS DRINKS LIMITED 21,125,164 2,538 83.4%
AMPATHCARE 36,632,577 2,310 85.1%
GULF AFRICAN BANK LIMITED 44,549,794 2,300 88.3%
KIRINYAGA UNIVERSITY 28,199,966 2,153 78.7%
NORTHERN RANGELANDS TRUST 18,119,228 2,125 80.3%
KENYA NATIONAL BUREAU OF STATISTICS 54,757,267 1,821 97.9%
BRAEBURN SCHOOLS LIMITED 21,657,679 1,667 97.8%
COASTAL BOTTLERS LTD. 12,059,626 1,631 82.3%
KENYA ORDNANCE FACTORIES CORPORATION … 11,417,798 1,315 87.3%
MKOMANI CLINIC SOCIETY 6,673,414 1,212 76.6%
THE AGA KHAN ACADEMY 23,031,574 1,175 90%
FURNITURE PALACE INTERNATIONAL (K) LI… 8,157,236 1,064 90.1%
UNGA HOLDINGS LIMITED 18,858,775 1,022 77.8%
M-GAS LIMITED 24,643,261 1,019 98.8%
PEMBE FLOUR MILLS LIMITED 10,282,241 1,004 91.3%

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% 71 39 27,770 12 19,371 11 132,498,433 4 8,551 3 193,141,351 6
2024 <50% 101 50 35,230 12 22,657 12 226,260,556 5 11,333 3 334,982,583 8
2025 <50% 114 63 59,536 32 30,001 29 766,596,158 22 37,033 17 561,016,859 22
2023 >50%, <75% 31 17 20,506 9 16,887 10 384,579,822 12 27,353 9 262,057,829 8
2024 >50%, <75% 40 20 95,271 34 68,638 35 1,570,323,953 36 116,740 33 1,051,445,502 27
2025 >50%, <75% 26 14 52,883 28 30,949 30 1,127,297,962 33 61,018 27 648,499,460 25
2023 >75%, <100% 30 16 66,899 30 54,223 31 1,148,115,164 34 83,301 26 917,779,865 27
2024 >75%, <100% 33 16 127,924 45 87,424 45 2,250,912,190 52 187,013 53 2,105,465,962 53
2025 >75%, <100% 21 12 75,233 40 41,029 40 1,534,906,907 45 124,478 56 1,341,579,535 52
2023 >100% 51 28 108,131 48 86,211 49 1,678,874,024 50 195,600 62 2,027,870,724 60
2024 >100% 29 14 25,054 9 16,801 9 316,008,205 7 34,830 10 469,896,782 12
2025 >100% 19 11 1,252 1 519 1 15,016,391 0 1,644 1 25,622,584 1
2023 TOTAL 183 100 223,306 100 176,692 100 3,344,067,443 100 314,805 100 3,400,849,769 100
2024 TOTAL 203 100 283,479 100 195,520 100 4,363,504,904 100 349,916 100 3,961,790,829 100
2025 TOTAL 180 100 188,904 100 102,497 100 3,443,817,417 100 224,173 100 2,576,718,438 100

✅ 5 Wins

  • In 2024, Lives Insured % in the '>100%' band decreased by 39 points compared to 2023.
  • In 2024, Person Years % in the '>100%' band decreased by 40 points compared to 2023.
  • In 2024, EP Per Year % in the '>100%' band decreased by 43 points compared to 2023.
  • In 2024, Claim Count % in the '>100%' band decreased by 52 points compared to 2023.
  • In 2024, Total Amount % in the '>100%' band decreased by 48 points compared to 2023.

⚠️ 5 Losses

  • In 2024, Lives Insured % in the '>75%, <100%' band increased by 15 points compared to 2023.
  • In 2024, Person Years % in the '>75%, <100%' band increased by 14 points compared to 2023.
  • In 2024, EP Per Year % in the '>75%, <100%' band increased by 18 points compared to 2023.
  • In 2024, Claim Count % in the '>75%, <100%' band increased by 27 points compared to 2023.
  • In 2024, Total Amount % in the '>75%, <100%' band increased by 26 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 > 50 - 2025
Channel
Lives Insured
2023
2024
2025
Earned Premium Claim Ratio Earned Premium Claim Ratio Earned Premium Claim Ratio
KAISA 354 12,947,182 79.6% 19,975,169 125.8% 4,195,269 161.4%
KIOTA 341 1,785,661 299.8% 9,564,321 85.2% 3,875,240 116.2%
ROYALSFIELD 72 3,256,214 63.9% 3,239,497 47.1% 604,677 129%
KANKAWA 98 472,452 0% 1,544,151 72.9% 3,299,929 135%
FINCORP INSURANCE AGENCY LIMITED 66 NA NaN% 9,840 0% 143,246 240.1%
ALLISTER SMITH INSURANCE AGENCY LTD 67 NA NA% NA NA% 1,149,235 109.3%
KNIGHTSBRIDGE INSURANCE AGENCIES LTD 59 NA NaN% NA NaN% 224,352 153.6%
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 51972 1,175,866,398 118.1% 1,698,059,526 96.1% 1,069,528,138 85.9%
SEDGWICK 5648 11,593,859 98.2% 75,831,560 124.2% 96,705,953 99.5%
ZAMARA 5409 127,247,752 124.6% 37,023,083 81.6% 148,442,454 88.4%
THANAWALLA 2587 5,355,972 94.7% 33,213,539 115.9% 44,376,663 89.5%
MINET 1946 78,615,807 82.5% 35,208,026 82.4% 22,082,664 80.3%
ALLION 1620 16,616,321 84.8% 19,964,752 61% 7,220,465 92.1%
GENISTINE 1531 21,604,927 134.9% 51,672,404 115.5% 30,671,520 92.8%
DTB 1396 63,750,099 106.2% 26,004,058 463.2% 40,640,037 80%
PELICAN 936 NA NA% 5,703,308 96.5% 33,040,003 99.2%

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 100.45 >100% 223,306 100 176,692 100 3,390,972,578 100 315,335 100 3,406,220,172 100
ALL LOBs 2024 90.01 >75%, <100% 283,479 100 195,520 100 4,406,577,285 100 350,159 100 3,966,189,182 100
ALL LOBs 2025 74.94 >50%, <75% 188,904 100 102,497 100 3,530,937,772 100 230,095 100 2,646,058,404 100
COMMUNITY 2023 86.00 >75%, <100% 10,579 5 6,064 3 161,846,225 5 665 0 138,628,200 4
COMMUNITY 2024 278.00 >100% 15,744 6 10,399 5 76,255,819 2 1,015 0 212,075,420 5
COMMUNITY 2025 203.00 >100% 11,044 6 5,708 6 81,389,527 2 799 0 165,418,179 6
CORPORATE 2023 103.00 >100% 202,421 91 163,216 92 3,006,334,770 89 303,711 96 3,094,811,788 91
CORPORATE 2024 89.00 >75%, <100% 253,443 89 175,518 90 4,100,612,399 93 345,683 99 3,630,517,513 92
CORPORATE 2025 73.00 >50%, <75% 158,396 84 88,050 86 3,124,479,549 88 219,942 96 2,289,182,786 87
RETAIL 2023 38.00 <50% 9,031 4 6,454 4 177,042,211 5 2,147 1 68,005,812 2
RETAIL 2024 52.00 >50%, <75% 13,043 5 8,779 4 199,903,308 5 2,549 1 104,736,324 3
RETAIL 2025 57.00 >50%, <75% 17,912 9 7,834 8 299,231,235 8 8,372 4 170,402,776 6
SME 2023 229.00 >100% 1,275 1 959 1 45,749,371 1 8,812 3 104,774,372 3
SME 2024 63.00 >50%, <75% 1,249 0 824 0 29,805,759 1 912 0 18,859,925 0
SME 2025 81.00 >75%, <100% 1,552 1 906 1 25,837,461 1 982 0 21,054,663 1

📊 Line of Business Observations

📈 Claim Ratio Growth
2023 vs 2024:
  • ALL LOBs: Claim ratio decreased by 10.4% from 100.5% to 90.0%.
  • COMMUNITY: Claim ratio increased by 192.0% from 86.0% to 278.0%.
  • CORPORATE: Claim ratio decreased by 14.0% from 103.0% to 89.0%.
  • RETAIL: Claim ratio increased by 14.0% from 38.0% to 52.0%.
  • SME: Claim ratio decreased by 166.0% from 229.0% to 63.0%.

2024 vs 2025:
  • ALL LOBs: Claim ratio decreased by 15.1% from 90.0% to 74.9%.
  • COMMUNITY: Claim ratio decreased by 75.0% from 278.0% to 203.0%.
  • CORPORATE: Claim ratio decreased by 16.0% from 89.0% to 73.0%.
  • CORPORATE: Proportion of lives decreased by 5.0%.
  • CORPORATE: Share of earned premium decreased by 5.0%.
  • RETAIL: Claim ratio increased by 5.0% from 52.0% to 57.0%.
  • SME: Claim ratio increased by 18.0% from 63.0% to 81.0%.

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 51 2,206
2024 12 50 2,209
2025 12 41 1,907
🔍 Provider Payout Concentration Insights: Over-concentrated if total payments make up less than 30%
  • 2023: Over-concentration at the 50th Percentile: only 13 providers (0.6%) accounted for 50% of payouts. Over-concentration at the 75th Percentile: just 51 providers (2.3%) accounted for 75% of payouts.
  • 2024: Over-concentration at the 50th Percentile: only 12 providers (0.5%) accounted for 50% of payouts. Over-concentration at the 75th Percentile: just 50 providers (2.3%) accounted for 75% of payouts.
  • 2025: Over-concentration at the 50th Percentile: only 12 providers (0.6%) accounted for 50% of payouts. Over-concentration at the 75th Percentile: just 41 providers (2.1%) 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 370,625,426 10.9% 1 367,348,721 9.3% 1 278,235,821 10.5% 1
AVENUE HEALTHCARE LTD 212,373,452 6.2% 2 259,644,621 6.5% 2 177,304,606 6.7% 2
EQUITY AFIA LIMITED 120,203,489 3.5% 6 210,015,204 5.3% 3 135,980,651 5.1% 3
SOCIAL SERVICE LEAGUE M.P. SHAH HOSPITAL 161,153,907 4.7% 4 204,824,808 5.2% 4 132,001,670 5.0% 5
KENYA HOSPITAL ASSOCIATION 166,976,218 4.9% 3 202,603,297 5.1% 5 135,232,152 5.1% 4
GERTRUDES CHILDRENS HOSPITAL 141,167,454 4.1% 5 150,050,095 3.8% 6 110,397,779 4.2% 6
THE AGA KHAN HOSPITAL KISUMU 105,952,175 3.1% 7 140,935,577 3.6% 7 103,620,505 3.9% 7
THE AGA KHAN HOSPITAL MOMBASA 98,580,743 2.9% 8 117,689,594 3.0% 8 64,523,270 2.4% 8
PANDYA MEMORIAL HOSPITAL 77,545,666 2.3% 9 96,637,871 2.4% 9 55,419,735 2.1% 12
OPTICA 76,778,912 2.3% 10 87,993,461 2.2% 10 62,752,710 2.4% 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 (GEN HOSP / OUT-PATIENT / OPTICAL / MATERNITY, 2023–2025)
Average Cost
GEN HOSP
OUT-PATIENT
OPTICAL
MATERNITY
Provider 2023 2024 2025 2023 2024 2025 2023 2024 2025 2023 2024 2025
AVENUE HEALTHCARE LTD 100,783 135,188 131,704 5,733 6,067 6,596 12,268 7,213 7,766 145,545 110,087 87,806
GERTRUDES CHILDRENS HOSPITAL 139,446 212,967 203,469 6,148 6,849 7,271 7,493 6,460 7,614 NA NA NA
INDIA HOSPITAL 52,791 63,018 64,357 6,230 7,390 6,752 15,098 12,057 12,457 39,965 18,346 NA
KENYA HOSPITAL ASSOCIATION 115,294 171,672 166,950 7,275 7,882 8,241 8,126 2,521 4,399 68,731 96,180 58,279
PANDYA MEMORIAL HOSPITAL 114,034 145,046 153,980 3,296 3,547 3,794 NA 4,669 NA 67,285 85,245 169,348
SOCIAL SERVICE LEAGUE M.P. SHAH HOSPITAL 130,829 230,042 195,105 4,422 4,863 4,771 3,531 5,202 8,667 109,504 148,892 143,333
THE AGA KHAN HOSPITAL KISUMU 104,733 157,294 178,008 3,354 3,675 3,928 11,978 10,694 11,506 100,128 137,039 93,903
THE AGA KHAN HOSPITAL MOMBASA 112,130 141,133 152,579 2,969 3,098 3,055 13,557 15,962 18,967 91,829 137,581 84,235
THE AGA KHAN UNIVERSITY HOSPITAL 287,361 294,599 273,470 4,213 4,513 4,807 6,955 8,021 10,396 130,578 113,401 120,869
EQUITY AFIA LIMITED NA NA NA 3,712 3,643 3,700 11,630 11,718 11,333 12,446 6,580 NA
OPTICA NA NA NA 11,424 8,552 2,996 15,149 14,569 13,875 NA NA NA
📋 Top 10 Priority 2 Providers – Average Cost by Benefit (GEN HOSP / OUT-PATIENT / OPTICAL / MATERNITY, 2023–2025)
Average Cost
GEN HOSP
OUT-PATIENT
OPTICAL
MATERNITY
Provider 2023 2024 2025 2023 2024 2025 2023 2024 2025 2023 2024 2025
AAR HEALTHCARE KENYA LIMITED 15,426 7,000 3,259 5,566 5,571 5,765 9,476 7,268 3,701 NA NA NA
AAR HOSPITAL LIMITED 85,167 202,706 194,995 3,994 3,835 4,324 4,000 2,815 8,175 117,553 149,871 158,675
BRISTOL PARK HOSPITAL LIMITED 70,481 91,130 86,176 4,970 4,776 4,305 17,681 18,862 9,381 39,823 89,076 55,949
COPTIC HOSPITAL 115,660 166,286 140,137 2,737 4,226 5,235 5,197 4,874 3,500 82,216 127,586 157,532
MEDINA MEDICARE HOSPITAL LIMITED 83,448 64,780 63,361 5,346 5,636 6,656 18,614 14,914 13,233 39,121 100,000 57,820
METROPOLITAN HOSPITAL NAIROBI 87,288 104,359 84,635 3,092 5,446 5,906 8,663 12,229 10,477 66,485 95,867 66,136
MOMBASA HOSPITAL ASSOCIATION 182,518 227,799 220,769 8,558 9,058 9,565 NA NA NA 101,772 96,293 130,798
PREMIER HOSPITAL LIMITED 104,594 136,201 120,215 5,698 6,624 6,943 9,000 NA NA 71,833 83,113 132,462
THE MATER HOSPITAL 98,370 145,154 200,608 3,476 5,259 6,150 9,215 NA NA 121,858 70,821 83,657
THE NAIROBI WOMENS HOSPITAL 61,294 71,974 74,264 4,179 3,908 4,560 11,399 13,500 12,750 107,049 52,563 56,300

Average cost insights:

💡 Benefit-specific Insights (Comprehensive_Claims_Data) — Top 10 per Priority (2024→2025)

📌 Priority 1 (Top 10)
  • OPTICA decreased by 65% in OUT-PATIENT from KES 8,552 to KES 2,996.
  • SOCIAL SERVICE LEAGUE M.P. SHAH HOSPITAL increased by 66.6% in OPTICAL from KES 5,202 to KES 8,667.
  • PANDYA MEMORIAL HOSPITAL decreased by 100% in OPTICAL from KES 4,669 to KES 0.
  • KENYA HOSPITAL ASSOCIATION increased by 74.5% in OPTICAL from KES 2,521 to KES 4,399.
  • PANDYA MEMORIAL HOSPITAL increased by 98.7% in MATERNITY from KES 85,245 to KES 169,348.
  • EQUITY AFIA LIMITED decreased by 100% in MATERNITY from KES 6,580 to KES 0.
📌 Priority 2 (Top 10)
  • AAR HEALTHCARE KENYA LIMITED decreased by 53.4% in GEN HOSP from KES 7,000 to KES 3,259.
  • BRISTOL PARK HOSPITAL LIMITED decreased by 50.3% in OPTICAL from KES 18,862 to KES 9,381.
  • AAR HOSPITAL LIMITED increased by 190.4% in OPTICAL from KES 2,815 to KES 8,175.
  • PREMIER HOSPITAL LIMITED increased by 59.4% in MATERNITY from KES 83,113 to KES 132,462.
  • MEDINA MEDICARE HOSPITAL LIMITED increased by 54966.7% in MATERNITY from KES 105 to KES 57,820.

🔎 Investigate (>|70% YOY| or new activity) — Top 10 only (2024→2025)

Priority 1 (Top 10)
  • KENYA HOSPITAL ASSOCIATION
  • PANDYA MEMORIAL HOSPITAL
Priority 2 (Top 10)
  • AAR HOSPITAL LIMITED
  • MEDINA MEDICARE HOSPITAL LIMITED

Average Cost By each Sub Benefit Type per Provider

BENEFIT 2023 2024 2025 Prev Report Average
GENERAL HOSPITALIZATION 115,294 171,672 166,950 168,231
OUT-PATIENT 7,275 7,882 8,241 8,039
DENTAL 10,015 9,624 11,892 14,607
OPTICAL 8,126 2,521 4,399 4,399
MATERNITY 83,634 95,310 93,061 89,110

Top Providers to Date

2023
2024
2025
Service Provider Amount % Rank Amount % Rank Amount % Rank
THE AGA KHAN UNIVERSITY HOSPITAL 241,910,928 10% 1 283,449,527 10.2% 1 303,301,308 9.6% 1
AVENUE HEALTHCARE LTD 156,943,387 6.5% 2 177,249,053 6.4% 2 186,743,570 5.9% 2
EQUITY AFIA LIMITED 78,719,798 3.3% 6 139,192,911 5% 3 157,716,051 5% 3
SOCIAL SERVICE LEAGUE M.P. SHAH HOSPITAL 110,949,981 4.6% 4 124,689,437 4.5% 5 145,907,357 4.6% 4
KENYA HOSPITAL ASSOCIATION 119,438,928 5% 3 133,456,365 4.8% 4 143,608,004 4.5% 5
THE AGA KHAN HOSPITAL KISUMU 74,039,633 3.1% 8 102,369,383 3.7% 7 112,101,802 3.5% 6
GERTRUDES CHILDRENS HOSPITAL 105,214,261 4.4% 5 109,900,901 4% 6 103,803,037 3.3% 7
THE AGA KHAN HOSPITAL MOMBASA 75,674,559 3.1% 7 87,086,706 3.1% 8 72,766,954 2.3% 8
THE MATER HOSPITAL 49,531,485 2.1% 11 43,679,676 1.6% 12 67,965,328 2.1% 9
OPTICA 52,400,575 2.2% 9 62,906,684 2.3% 10 65,730,359 2.1% 10

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 53 285
🔍 Ailment Payout Concentration Insights: Over-concentrated if total payments make up less than 30%
  • 2023: Over-concentration at the 50th Percentile: only 15 ailments (5.1%) accounted for 50% of payouts. Over-concentration at the 75th Percentile: just 48 ailments (16.4%) accounted for 75% of payouts.
  • 2024: Over-concentration at the 50th Percentile: only 17 ailments (5.8%) accounted for 50% of payouts. Over-concentration at the 75th Percentile: just 49 ailments (16.7%) accounted for 75% of payouts.
  • 2025: Over-concentration at the 50th Percentile: only 18 ailments (6.3%) accounted for 50% of payouts. Over-concentration at the 75th Percentile: just 53 ailments (18.6%) 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 233,286,396 6.8% 1 266,863,035 6.7% 1 164,993,483 6.2% 1
 Diseases of esophagus, stomach and duodenum 181,700,547 5.3% 2 207,502,952 5.2% 2 122,370,632 4.6% 3
 Diseases of oral cavity and salivary glands 162,476,808 4.8% 3 198,329,104 5% 3 131,703,110 5% 2
 Disorders of ocular muscles, binocular movement, accommodation and refraction 145,335,053 4.3% 4 148,631,115 3.7% 4 96,600,656 3.7% 5
 Acute upper respiratory infections 140,302,307 4.1% 5 145,542,856 3.7% 5 82,429,841 3.1% 7
 Hypertensive diseases 116,795,192 3.4% 6 143,741,174 3.6% 6 104,284,617 3.9% 4
 General symptoms and signs 106,509,609 3.1% 7 119,291,528 3% 7 90,299,751 3.4% 6
 Influenza and pneumonia 82,514,466 2.4% 9 116,000,332 2.9% 8 67,661,849 2.6% 8
 Persons encountering health services in circumstances related to reproduction 104,211,841 3.1% 8 103,505,776 2.6% 9 56,025,697 2.1% 10
 Benign neoplasms, except benign neuroendocrine tumors 71,474,089 2.1% 10 96,145,150 2.4% 10 65,089,679 2.5% 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.
  •  Benign neoplasms, except benign neuroendocrine tumors entered top 10 in 2025 at position 10.
  •  Intestinal infectious diseases dropped out of top 10 in 2025.
  •  Diabetes mellitus entered top 10 in 2025 at position 9.

Average cost Analysis for the Ailments

🩺 Priority 1 Ailments - Average Cost (Ordered by 2024 Average Cost)
Average Cost
Ailment 2023 2024 2025 Prev Report Average
 Persons encountering health services in circumstances related to reproduction 36,425 27,053 21,458 24,355
 Benign neoplasms, except benign neuroendocrine tumors 23,116 25,388 27,876 20,741
 Disorders of refraction and accommodation 16,708 18,080 17,731 17,185
 Diabetes mellitus 15,571 16,051 18,437 14,317
 Influenza and pneumonia 13,612 14,198 15,466 12,849
 Disorders of ocular muscles, binocular movement, accommodation and refraction 14,125 13,748 12,805 13,281
 Diseases of oral cavity and salivary glands 11,143 11,431 11,598 10,902
 Hypertensive diseases 10,253 11,044 10,936 9,185
 Diseases of esophagus, stomach and duodenum 10,034 9,986 9,821 8,418
 Urolithiasis 8,549 9,135 8,627 7,356
 Intestinal infectious diseases 8,996 8,710 8,348 7,135
Chronic lower respiratory diseases 8,407 8,464 8,537 7,167
 General symptoms and signs 7,844 8,027 7,856 6,332
Other diseases of upper respiratory tract 6,527 6,704 6,143 5,594
 Acute upper respiratory infections 6,005 5,726 5,949 4,906
 Persons encountering health services for examinations 4,467 5,482 8,069 4,371
📋 Top 10 Priority 2 Ailments - Average Cost (Ordered by 2024 Average Cost)
Average Cost
Ailment 2023 2024 2025 Prev Report Average
 Ischemic heart diseases 97,697 116,518 64,149 66,953
 Disorders of gallbladder, biliary tract and pancreas 108,462 94,545 89,046 74,481
 Hernia 96,591 90,126 77,829 71,143
 Assault 85,695 68,526 92,688 62,950
 Birth trauma 27,754 35,886 28,944 26,807
In situ neoplasms 23,589 30,011 17,588 19,931
 Diseases of male genital organs 40,209 28,872 24,909 25,228
 Osteoarthritis 25,695 26,163 20,900 20,004
 Metabolic disorders 16,688 21,937 21,393 17,165
 Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals 19,654 20,924 19,732 16,614

💡 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 25.7% from KES 36,425 to KES 27,053.
  •  Persons encountering health services for examinations increased by 22.7% from KES 4,467 to KES 5,482.
2024–2025:
  •  Persons encountering health services in circumstances related to reproduction decreased by 20.7% from KES 27,053 to KES 21,458.
  •  Persons encountering health services for examinations increased by 47.2% from KES 5,482 to KES 8,069.
📌 Priority 2 Ailments
2023–2024:
  •  Assault decreased by 20% from KES 85,695 to KES 68,526.
  •  Birth trauma increased by 29.3% from KES 27,754 to KES 35,886.
  • In situ neoplasms increased by 27.2% from KES 23,589 to KES 30,011.
  •  Diseases of male genital organs decreased by 28.2% from KES 40,209 to KES 28,872.
  •  Metabolic disorders increased by 31.4% from KES 16,688 to KES 21,937.
2024–2025:
  •  Ischemic heart diseases decreased by 44.9% from KES 116,518 to KES 64,149.
  •  Assault increased by 35.3% from KES 68,526 to KES 92,688.
  • In situ neoplasms decreased by 41.4% from KES 30,011 to KES 17,588.
  •  Osteoarthritis decreased by 20.1% from KES 26,163 to KES 20,900.

Claim Distribution By Age Profile

Current Year (To Date) Claims Paid Analysis

Reconciliation

📊 Mid-Year Claims vs Financials Reconciliation
Loss_Year Paid_bordereaux Financials Difference Percent_Diff
2023 2,412,036,938 2,414,378,280 -2,341,342 -0.1%
2024 2,775,127,916 2,771,113,234 4,014,682 0.1%
2025 3,171,366,305 3,192,002,006 -20,635,701 -0.6%

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 510,091,113 25,433,530 10,449,705
2023 1,901,905,376 492,621,316 24,484,557
2024 0 2,257,034,208 588,795,007
2025 0 0 2,547,591,341
NA 40,449 38,862 45,696
Total Paid 2,412,036,938 2,775,127,916 3,171,366,305
Current-Year Paid 1,901,905,376 2,257,034,208 2,547,591,341
Reserve Utilized 510,131,562 518,093,709 623,774,964
Reserves 92,619,028 310,062,088 234,082,334
(Over)/Under Utilization -417,512,534 -208,031,621 -389,692,630

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 1 850,738,906 23.7 1
I&M 381,856,155 8.8 2 562,075,410 11.8 2 551,030,018 15.3 2
CSI 356,390,907 8.2 3 464,269,598 9.7 3 341,389,952 9.5 3
D&G 189,084,906 4.4 5 196,747,323 4.1 4 191,565,978 5.3 5
CHESTER 201,904,122 4.7 4 176,858,095 3.7 5 136,309,864 3.8 7
SEDGWICK 11,232,834 0.3 32 124,638,058 2.6 6 137,856,254 3.8 6
BTB 125,856,332 2.9 7 95,487,821 2.0 7 66,871,537 1.9 9
AMS 3,116,845 0.1 87 78,251,049 1.6 8 81,171,016 2.3 8
DTB 62,691,166 1.4 10 76,243,876 1.6 9 54,335,581 1.5 13
MTN 65,816,063 1.5 9 76,116,999 1.6 10 17,765,711 0.5 24

Areas of improvement

💡 Recommendations

  1. Intermediary Mapping: Introduce a seperate Bancassurance intermediary category to track the performance of bancassurance intermediaries.
  2. Year-to-Date Comparisons: Incorporate a year-to-date (YTD) comparison of premium, exposure, and covered lives to provide real-time monitoring of portfolio growth and retention dynamics.
  3. Revisit and Ailment Cost Analysis: Conduct a focused review of revisit rates and ailment-specific average costs among the major (high-concentration) providers to identify potential areas for cost containment and efficiency improvement.
  4. Benefit Utilization by Limit: Implement an analysis of benefit utilization by benefit limit to evaluate the adequacy of limits and identify potential pricing or benefit design adjustments.