Management summary

Scope: UNDERWRITING YEARS 2024–2026. Claims are valued to 26 August 2026 on the payable amount basis.

The portfolio’s known LR is 92.1%, but the average masks a sharp split. Community products have a higher loss ratio (LR) than retail. Community’s deficit is concentrated in a few products and reflects mainly higher claim frequency, especially in Chronic and General Hospitalisation. Claims costs also vary by attained age with older age groups costing more.

Portfolio known payable LR
92.1%
Before expenses and other costs
Retail known payable LR
73.5%
Matched premium / exposure book
Community known payable LR
111.2%
Matched premium / exposure book

Finding 1. Community is above written premium while Retail is below

Community’s known LR is 111.2%, compared with 73.5% for Retail. The combined portfolio result underscores different segment experience.

Finding 2. A small number of standardised Community products explain most of the deficit

Standardised products driving the Community deficit: HINDU COUNCIL OVERALL 65-75; HINDU COUNCIL OVERALL 2M; HINDU COUNCIL OVERALL 5M

Together, these groups account for about 93.7% of the claims above premium from loss-making Community products. Further analysis could not be done without further data such as benefit limits per member.

Finding 3. Chronic and General Hospitalisation drive most of the Community frequency gap

Community holds about 23.6% more claim events per unit of exposure than Retail. Chronic explains about 59.7% of the net frequency gap and General Hospitalisation another 30.0%.

Finding 4. Short-interval repeat visits are more common in Community

19.2% of Community claim events occur within 1–7 days of the previous claim event, compared with 16.8% for Retail.

Finding 5. Older-age claims costs vary across observed bands

Across the observed older-age bands, claims cost per member-year ranges from KSh 54k to KSh 63k, with the highest observed level in age band 75+. INPUT REQUIRED - no product age-limit table supplied.

Key limitations

  • Pricing and age-extension inputs: Benefit limits, product terms, expenses, commissions, target loss ratios and the inputs required for absolute age-extension scenarios are incomplete. The review identifies claims pressure and age patterns but does not set revised premiums or final age limits.
  • Exposure and classification: Policy period was assumed to be 1 year from the invoice transaction date and classfication of retail and community was based on the name of the products.
  • Missing premium and duplicate review: KSh 53.3m of claims are found in I&M Retail-related products could not be attached to their respective coverage periods and are excluded from the base LR.
  • Provider data: Provider mapping is incomplete as there are some providers not in the provided provider mappings.

Supporting detail

Financial experience

Underwriting-year financial review

Product experience

Frequency and severity statistics

Benefit frequency-gap decomposition

Diagnosis evidence

Repeat visits

Large claims

Top claim events

Provider / tier diagnostics

Older-age experience

Older-age benefit experience

Age-extension scenarios

Scenario status: INPUT REQUIRED - no product age-limit table supplied

Age-standardised validation

Missing-premium claim mapping

total_missing_premium_claim_events total_missing_premium_claims mapped_claim_events mapped_claims event_mapping_coverage claim_amount_mapping_coverage reconciliation_to_missing_premium_register status all_mapped_im_claims_retail interpretation
451 53332970 451 53332970 1 1 0 PASS - CLAIM-ONLY MAPPING RECONCILES TO MISSING-PREMIUM CLAIMS TRUE Product/segment mapping is diagnostic only. No missing premium or exposure is manufactured.

Retail / Community classification

Controls and provenance

Item Value
Evidence file retail_community_review_RCMR-20260922-162822.rds
Run ID RCMR-20260922-162822
Critical controls passed 27
Critical controls failed 0
IBNR scope control
Claim matching summary

Assumptions and limitations

  • The main profitability comparison uses written premium and known payable claims for the matched review-scope book.
  • Estimated ultimate results are data-based and therefore provisional.
  • Claims on policies absent from the premium data are shown separately as we could not attach them to the respective coverages.
  • Retail / Community classification remains provisional pending business confirmation.
  • Provider-tier conclusions are descriptive and subject to unmapped / ambiguous provider records.
  • Diagnosis-level interpretation is limited by inconsistent raw clinical labels; the management conclusion is therefore made at benefit level.
  • Claims experience alone does not determine a final technical or commercial premium. Final pricing requires the applicable target, expenses / commissions where relevant, benefit design and other underwriting inputs.
  • Attained-age experience is used for utilisation, frequency, severity and claims cost. It does not manufacture age-level premium or loss ratios.
  • Age-extension scenario results are decision-ready only where the required age limits, exact-age experience, pricing target and incremental exposure assumptions are available; otherwise the scenario output remains preliminary or blocked.
  • The severity comparison supporting Finding 3 is adjusted for age band, underwriting year, benefit group and provider-tier group (multivariate_segment_effect_summary). The adjusted Community/Retail severity ratio is not statistically distinguishable from 1.