DHA / DOH compatible · Standardized format

Drop a claims report. Get an underwriting brief.

Universal claims analyzer for UAE group medical. Reads any DHA-format claims report and produces an underwriter-ready brief in under a minute.

OR
⚙
Reproducible
Same inputs → same outputs. Every parameter and assumption is logged with full audit trail.
⚐
Anomaly detection
Sanity-checks claims data for incomplete months, mismatched totals, and tail-month drops.
⇄
What-if simulation
Live plan-design lever simulator. Adjust pharmacy co-ins, room category, network — see the premium move.
Cases / Renewals 2026 / Metscon IT Systems
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Metscon IT Systems (L.L.C.)

995 lives IT services Dubai · DHA May'25 → Feb'26 · 9.5mo Data quality 78/100
▤
Executive abstract
A 995-life IT services group with 9.5 months of claims experience. Annualized burning cost lands at — (—), computing…. No catastrophic clinical signals — no malignancy, dialysis, or transplant activity in-period. Two items earn the underwriter's attention: pharmacy share at 24% approaching the soft threshold, and out-of-network unit cost 3.1× in-network on a small but concentrated leakage. Data integrity is reasonable but not clean — IBNR appears light, the tail month under-developed, and 2.5 months of the policy year remain unobserved. Recommended next step: request the missing months, pin parameters, and walk through the plan-design simulator with the broker.
◐
Ultimate claims
AED3.97m
full credibility
◢
Burning cost
AED3.82m
PPPY 3,841 · ↑ 6.4% vs prior
◇
Indicative gross premium
AED4.78m
PPPY 4,802 · at default loads
◆
Data quality
78/ 100
⚑ 3 watchpoints
02 · Data quality

Data integrity check

Automated sanity checks on the source claims report. Red flags require attention before pricing; yellow are noted but typically tolerable; green indicates clean data.

8 checks · 1 red · 3 yellow · 4 green
!
Top claimant vs top provider mismatch Anomaly
Top claimant total reported as AED 198,400 but the top provider's spend on this member shows only AED 109,200. Possible classification error or split-billing. Reconciliation needed before finalizing.
Request reconciliation from broker →
⚐
Incomplete observation period Coverage
Only 9.5 months of the policy year provided (May'25 → Feb'26). 2.5 months remain unobserved. Annualization assumes the unseen months track selected-month average.
Request remaining months →
⚐
Tail-month under-development Reserving
February paid claims dropped to AED 316k vs nine-month average of AED 380k (−16%). Likely incomplete processing at report cut-off. Auto-excluded from run-rate; can be re-included via month chips.
⚐
IBNR reserve appears light Reserving
Reported IBNR is 0.5% of processed claims; market median for a 9.5-month tail is 4–7%. Combined RBNP+IBNR at 8.3% is also below typical 10–15%. Top-up reserve recommended.
✓
No catastrophic clinical signals Clinical
No malignancy, dialysis, or transplant activity detected in-period. No claims above AED 200k from a single event.
✓
No fraud-pattern indicators Anomaly
No weekend/holiday spikes, no unusual claim-frequency clusters, no provider-concentration outliers beyond expected geography.
✓
Source totals reconcile Integrity
Sum of monthly paid claims (AED 3,547,994) matches header total within 0.01%. Diagnosis-level value sums to 97.3% of total — within tolerance.
✓
Demographic coverage complete Census
All 995 closing lives mapped to age band and relationship. Nationality coverage at 98.0% (2% other). Sufficient for one-way pricing cross-check.
03 · Claims

Claims overview

Over 9.5 months the group incurred AED 3.55m in processed claims with light reserves, projecting to an annualized burning cost of AED 3.82m. Two items are notable.

Processed claims
3,547,994
Reserves (RBNP + IBNR)
296,400 · 8.3% (light)
Total incurred
3,844,394
Annualized burning cost
3,824,512
Pharmacy share ?
24.0% · watch
Out-of-network share
4.6% · avg 3.1× in-net
Catastrophic signals
None

By service category

Outpatient
53.9%
Pharmacy
23.9%
Inpatient
21.2%
Dental
0.9%
Optical
0.1%
04 · Monthly

Monthly claims

Toggle months to include in the run-rate calculation. Defaults exclude ramp-up (May'25) and tail drop (Feb'26). Every figure on this page updates live as you change the selection.

8 of 10 months · annualized ×12
Selected sum
AED 2.55m
Annualized
AED 3.82m
Monthly avg
AED 319k
Months
05 · Comparison

vs prior year · book · market

Three independent reference frames. Prior year shows how this group is trending against itself; book benchmark is the insurer's expectation for similar IT/Tech groups; UAE market uses DHA-published industry norms.

Metric FY25 (prior) FY26 (current) Book benchmark UAE market Verdict
Burning cost (PPPY) 3,610 3,841 4,680 4,420 −18% vs book
Pharmacy share 21.0% 24.0% 22.0% 23.5% +3pp YoY · watch
Out-of-network share 4.2% 4.6% 5.5% 6.0% below book
Avg claim size (AED) 368 383 410 395 below book
Maternity rate 3.8% 3.2% 4.5% 4.8% below market
Diabetes prevalence 4.7% 5.8% 6.2% 7.1% +1.1pp YoY
Claim frequency (per 1k lives) 8,720 9,260 8,100 8,500 +14% vs book
Avg lives 890 995 — — +11.8% growth
06 · Clinical

Top ten diagnoses

Physician-reviewed commentary on the highest-spend diagnosis groups. Flagged rows (⚑) are conditions the underwriter should actively consider — either because they carry forward-year escalation risk, or because they drive current pricing.

No malignancy · no dialysis · no transplant
Diagnosis Value Count Avg Trend Physician note
⚑
Other dorsopathies Chronic
196,608309636
Back & musculoskeletal. High frequency, moderate severity.
—
Acute upper respiratory Acute
192,5891,182163
Cold/flu. Volume driver, not cost driver.
⚑
Diabetes mellitus Escalating
186,809288649
UAE prevalence ~19%. CDM enrollment recommended.
—
Acute lower respiratory Acute
100,802419240
Pneumonia/bronchitis. No escalation pattern in-period.
⚑
Other joint disorders Chronic
92,257311297
Arthropathies. Steady cost curve.
—
Female genital tract Gynae
84,130254331
Routine gynae. Expected for the married-female cohort.
⚑
Urolithiasis Recurrent
83,194651,280
Kidney stones. Hydration program is the lever.
—
Maternity care Expected
78,405203,920
3.2% rate — below market average. No outliers.
—
Circ./resp. symptoms Workup
73,791386191
Diagnostic workups. 100% outpatient. Benign.
—
Shoulder/upper arm injury Injury
72,070292,485
Sport/accident. Isolated events.
07 · Providers

Where care happens

Top providers by spend share. vs Book compares this group's average claim at the provider against the book average for the same provider. Values above 1.0× indicate higher-than-expected billing.

Provider Share Value Visits Avg claim vs Book
Zulekha Hospital · Nahda Dubai
180,8701989130.96×
NMC Specialty · Nahda Dubai
150,7091579600.98×
NMC Specialty · Electra AD
118,2062065740.88×
NMC Royal · Sharjah
106,5691308201.22×
Zulekha · Sharjah
80,1351624951.02×
Emirates Specialty · DHCC
76,6831525041.58×
Aster · Mankhool
70,1132133290.91×
Al Sharq · Fujairah
48,527984951.04×
Prime · Garhoud
47,994104,7991.28×
Aster · Silicon Oasis
39,5052391650.94×
08 · Census demographics

Who's in the group

Census splits and forward-year risk pools derived from member data. Maternity-eligible, chronic-prone (40+), and dependent ratio are the underwriter's leading risk indicators beyond raw age/gender.

Composition
Employees
782
78.6%
Spouses
128
12.9%
Children
85
8.5%
Marital status
Single
510
65.2%
Married
272
34.8%
Gender mix
Male
706
71.0%
Female
289
29.0%
Age distribution
0–17
86
8.6% · pediatric
18–35
615
61.8% · core
36–50
258
25.9% · chronic-prone
51+
36
3.7% · senior
Forward-year risk pools
▲
Maternity-eligible cohort: 138 members — married females aged 18–40. At UAE market rate of 4.5%/year, expect ~6 deliveries (current observed: 3.2% · 4–5 cases). Maternity reserve sufficient.
▲
Chronic-prone cohort (40+): 188 members, 18.9% of group. Diabetes/hypertension prevalence rises ~3× in this band. Already driving 38% of YoY diabetes-case growth.
●
Dependent ratio: 0.27 (213 deps / 782 emps) — below market (typical UAE IT 0.4–0.6). Dependent benefits less utilized; may indicate over-sized dependent benefit design.
●
Pediatric-eligible (0–5): 38 members — typical well-baby visit pattern, vaccination programs apply.
09 · Nationality

Nationality mix

Nationality is an independent predictor of cost in UAE group medical. Cross-referencing the group's mix against the one-way premium table gives a sanity check independent of claims experience.

NationalityLivesShareExpected PPPY
INIndian
617
3,820
PKPakistani
149
3,560
PHFilipino
80
3,120
EGEgyptian
50
5,240
LKSri Lankan
30
3,440
LBLebanese
30
8,100
AEUAE National
20
9,450
··Other
19
3,600
Sanity check

Expected PPPY purely from the nationality mix is AED 3,940. Actual claims-driven PPPY (annualized) comes in at AED 3,841 — a favorable −2.5% vs nationality-predicted, suggesting no adverse selection relative to mix.

Nationality-predicted PPPY
AED 3,940
Actual 3,841 · delta −2.5%
10 · Plan design

What-if simulator

Adjust benefit-design levers and watch the premium move. Each lever uses utilization data from this group's claims to estimate elasticity. Live calculation — drag to see impact instantly.

Plan-design what-if Live
Total simulated saving: AED 0 · 0.0%
Pharmacy co-insurance
Current 10% → 10%
Estimated saving: AED 0
OON co-insurance
Current 20% → 20%
Estimated saving: AED 0
Specialist GP-referral gate
Current Off → Off
Estimated saving: AED 0
Room category
Current Private → Private
Estimated saving: AED 0
Network tier
Current Tier 1 → Tier 1
Estimated saving: AED 0
Dental annual cap (AED)
Current 1,000 → 1,000
Estimated saving: AED 0
Baseline burning cost
AED 3.82m
Pre-simulation
Simulated burning cost
AED 3.82m
no levers active
Simulated gross premium
AED 4.78m
PPPY 4,802
11 · Broker scenarios

Impact calculator

Pre-computed scenarios for broker conversations. Premium impact is shown as the percentage change vs the baseline gross premium and the absolute AED amount. Useful for quick "what if we changed X?" questions.

Common broker scenarios
Baseline: AED 4.78m · PPPY 4,802
Scenario New premium Δ AED Δ %
12 · Levers

Directional levers

Angles to consider — not prescriptions. Savings ranges are indicative; the underwriter decides what fits the client, retention, and renewal dynamics.

Tighten out-of-network unit cost
OON sits at 4.6% of value but carries an average claim 3.1× in-network. Two top OON providers fall outside the managed network. Cost-control angles: reimbursement review, emergency-only carve-outs, or migration to an equivalent managed network.
OON access can be retention-sensitive, especially for senior cohorts.
Indicative
80–120k
50–75% of OON
High
Chronic disease management
58 active diabetes cases (+38% YoY) and persistent dorsopathies cohort. Structured CDM programs typically reduce downstream acute episodes; formulary discipline on maintenance medications compounds the effect.
Benefit-positive lever — usually easy to sell at renewal as an enhancement rather than a cut.
Indicative
80–160k
on chronic block
Medium
Control pharmacy drift
Pharmacy at 24% of spend, up from 21% prior year. Approaching the 30% soft threshold. Standard interventions: formulary discipline, generic-first substitution, cap review.
Exempt chronics via CDM — blanket cap enforcement hurts the sickest and triggers retention risk.
Indicative
85–170k
10–20% of pharmacy
Medium
Right-size dental limit
Dental spend is AED 32k / 0.9%; only ~23% member penetration against AED 1,000 limit. Either over-sized or poorly communicated. Rightsize or promote — direction depends on client priorities.
"Under-used" sometimes reflects awareness gaps, not over-provision. Check with HR before cutting.
Indicative
25–50k
premium pass-through
Low
13 · Pricing anchors

Reference premiums

Four independent anchors. Claims-rated comes live from experience and parameters. Book rate is auto-calculated from the book table × this group's demographic. The two manual fields are for benefit-rated and one-way premium intel.

These are reference anchors, not pricing recommendations. The underwriter makes the call; the tool shows the spread.
Claims-rated premium AutoFrom experience + parameters
4,780,000PPPY 4,804
Book rate AutoBook × this demographic
4,685,300PPPY 4,709
Benefit-rated premium EditFrom benefit-design pricing tool
One-way premium EditFrom nationality mix table
Anchor average
4,753,825AED
Spread (low → high)
370kAED · 7.7%
Current indication
4,780,000Claims-rated
Ready to push to the Technical Sheet. All parameters, month selection, and UW-input premiums carry over. Audit log captures every change.