From prevention evidence to an insurance decision
The protocol covers one crossing: from prevention evidence to a declared pricing, reserving or reinsurance decision. Clinical evaluation, health economics, actuarial judgement and institutional approval each keep their own methods and owners; the protocol connects them where evidence changes hands.
Where evidence travels
Prevention begins upstream. A programme changes care, behaviour or clinical risk; those changes may later appear in health records, utilisation and claims. As evidence travels down the chain, effects can attenuate, assumptions enter and the relevant population changes.
| Stage | The question at this stage | Owner |
|---|---|---|
| Programme delivery | What was delivered, who was reached, and who stayed? | Programme owner |
| Clinical outcome | Is the measure consistent, and does the comparison support the change? | Evaluator |
| Events avoided | Does the clinical pathway hold in this population, over this horizon? | Epidemiologist |
| Utilisation and cost | Which admissions and costs are counted, and at what unit cost? | Claims analytics |
| Claims | Which benefits, limits and waiting periods decide what the insurer would have paid? | Actuary |
| Portfolio effect | How do participation, mix, effect emergence and claims runout change the result? | Actuary |
The decisive crossing is from health evidence to a declared insurance use. A convincing clinical result becomes an actuarial assumption only through the steps below.
Each step closes with two acts
The qualified owner signs off the substance, and the Protocol Lead, held within the institution with functional independence, confirms that every required record exists.
- Define the decision. Before the evidence is evaluated, the decision owner records the decision, the population and period, the assumption that may change, and the maximum adjustment. A provider’s headline may already exist: it is the claim under review, not the evaluation.
- Agree the analysis plan. The data owner confirms what exists and how it links; the evaluator judges whether that data can support the comparison. The evaluator and decision owner then fix the comparison, diagnostics, fallback method and residual bias assessment. The plan is dated and frozen before the evaluation result is known.
- Review the evidence. A valid comparison comes before a number. Each diagnostic addresses a named threat: selection into the programme, regression to the mean, underlying trend and drop-out. When the comparison fails its diagnostics, the agreed fallback applies, or the case is redesigned, or it stops.
- Assess the claims impact. The actuary carries the supported effect to expected claims for the portfolio or treaty. For medical expense cover, each step is written as utilisation × unit cost. Every step has a source, an owner and low, central and high scenarios, including effect emergence within the period.
- Set the use limits. The decision owner records what the evidence may change, within the adjustment limit agreed in advance, for which decision and until when. The owner may use less, or none, and records the reasons.
- Monitor experience. The monitoring schedule names each indicator, its reporting lag, its owner and the step it reopens. Claims runout sets when experience can be read. Recognition can be maintained, increased, reduced or withdrawn.
Seven rules that hold in every case
The checks stay; the paperwork scales
| Depth | When it applies | What the case looks like |
|---|---|---|
| Light | Below the institution’s materiality threshold, reversible at next renewal, one function | One combined record and two gates |
| Standard | Material pricing or reserving assumption | Seven linked records, with gates between steps |
| Full | Reinsurance terms, capital, multi-year commitments, or reuse by another function | Seven records plus independent technical review |
The checks are the same at every depth; only the documentation changes. Where ordinary pricing, an experience study or a standard contract already resolves the question, that is the right route.
The protocol works alongside Solvency II, ICS, risk-based capital regimes, established pricing methods and professional standards. Balance-sheet, treaty, accounting and capital consequences are decided by the institution and, where applicable, its supervisors; the protocol documents the evidence those decisions rest on.