Al Jazira Takaful implemented the Overtreatment Detection Engine for medical claims management in Q4 2023 year with the active involvement of the Health Claims Department and in partnership with MAINS LAB, has delivered significant improvements in claims efficiency, cost control, and TPA oversight.

Rejection Rate

Health claim rejection rate have significant positive impact reflecting stricter detection logic and closer adherence to medical guidelines. The medical claims rejection rate was 12% for year 2024 for the approved claims submitted by Third party administrator.

Top Services Rejected

Histological examination
Uroflowmetry
Blood sugar express diagnostics

Business Impact

The deployment of the Overtreatment Detection Engine has improved profitability indicators for Al Jazira Takaful by reducing unjustified medical spending. In addition, it has reinforced control over TPA performance, ensuring greater transparency and accountability in the claims review process.

Al Jazira's Managing Director, Dr. Sager Nadershah, stated, “It is our top priority to provide our clients with the best-in-class coverage for fair premiums. To achieve this, it is crucial to have strict control over providers to prevent fraud, waste, abuse, and overtreatment. We adhere to the most modern clinical guidelines and regulations, and this project has allowed us to do so in a smart, automated way.”

MAINS LAB CEO, Yury Kuvshinov, added, “We are living in a rapidly evolving world, and cutting-edge AI technologies enable us to make health insurance truly effective and client-oriented. We are honored to be the partner of Al Jazira in this journey to support their ambitious vision.”

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