Assessment of Health Insurance Claims Experience in the National Health Insurance Authority

This study assesses the claims experience patterns in the National Health Insurance Authority and their implications for premium adequacy and scheme sustainability. Nigeria's transition from the National Health Insurance Scheme to the National Health Insurance Authority under the NHIA Act 2022 has renewed attention on the financial management of public health insurance. Claims management and experience analysis are central actuarial functions that determine whether premiums collected are sufficient to meet benefit obligations over time. This study uses secondary data sourced from NHIA operational reports, health maintenance organization submissions, and National Bureau of Statistics health expenditure data for the period 2019 to 2023. Claims frequency, severity, and combined loss ratios are computed and analyzed across plan categories and geopolitical zones. Regression analysis is used to identify variables driving claims variability. Findings reveal that loss ratios in the formal sector plan have exceeded 95 percent in three of the five years analyzed, indicating premium inadequacy relative to actual claims cost. The North West zone recorded the highest claims frequency, while the South West recorded the highest average claims severity. The study concludes that the NHIA faces a structural premium adequacy challenge requiring urgent actuarial review of benefit schedules and capitation rates. It recommends a comprehensive national claims experience study and annual actuarial review of NHIA premium rates to ensure long-term financial sustainability.

Keywords: health insurance, claims experience, NHIA, premium adequacy, loss ratio.