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We spent the last few months doing something slightly unusual, across six employer populations covering roughly 170,000 benefits-eligible employees.
Method first, because it determines how much weight to put on everything that follows.
For each employer, we ingested their plan riders and mapped every covered benefit along with its minimum value. We matched their medical claims against every one of those benefit triggers. We separately flagged completed health screenings that qualify for a wellness payment. Then we priced each opportunity we found at the rider's minimum — the lowest amount the plan would pay, never the highest.
That last choice is deliberate. It means the numbers below are a floor, not a projection.
Across those six populations, over measurement windows of two to three months each, we surfaced 17,142 supplemental benefit opportunities worth roughly $5.75 million. Every one of them was a moment where something that had already happened to an employee lined up with coverage that employee was already paying for.
One clarification before the interesting part, because it's the first question a good benefits leader asks. These are identified opportunities, not payments. A carrier still has to receive the claim and adjudicate it. What we can tell you is that the coverage was in force, the qualifying event was sitting in the claims data, and nobody had filed.
This is the structural finding, and it's the one worth carrying into your Open Enrollment planning.
In five of the six populations, the majority of the dollars sat in critical illness claims — between 50% and 82% of the total value we surfaced. High severity, low frequency. Exactly the kind of event you build a supplemental benefits pitch around. In the sixth, accident claims carried the majority of the value.
But in five of the six, the majority of the individual opportunities were health screenings — between 60% and 83% of the items we found. Low value each, high frequency, and attached to something the employee had already done anyway. The average value per opportunity ran from $181 to $631 across the six, because a handful of large critical illness opportunities sit alongside a great many small screening ones.
So the benefit carrying the most money is not the benefit employees miss most often. Those are two different problems, and most Open Enrollment communication only addresses the first one.
The six populations had almost nothing in common. They spanned technology and media, transportation, food and beverage, healthcare, professional services, and a PEO. Different demographics, different risk profiles, different benefits teams, different carriers. In every single one, employees had completed screenings that qualified for a payment and never filed for it.
Which rules something out. When the same gap opens simultaneously across six unrelated industries, the explanation isn't that employees didn't read their materials.
Think about what filing actually requires.
An employee has to recognize that something that already happened to them was a covered trigger. Then find the coverage, locate the rider, work out what documentation is needed, and submit it — usually inside a filing window that varies by policy and that nobody ever mentions.
For a broken arm, at least the trigger announces itself. Something happened, it hurt, there's a bill, and it's plausibly an accident claim.
For a health screening, none of that is true. Nothing bad happened. The employee went to a routine appointment, had a routine test, and went back to work. There's no bill that prompts a question, no moment that says this was a covered event. The wellness benefit attached to it lives in a document they've never opened, describing coverage they elected eleven months ago in fifteen minutes between meetings.
The system is asking employees to notice the absence of something. That's a hard thing to ask of anyone, in any industry, at any level of benefits fluency. Our data says so plainly.
Most benefits teams report supplemental election rates, and reasonably so. It's the number the platform hands you, and it moves when your communication works.
But an election is a premium. The benefit only exists once a claim is filed and paid. A program with strong participation and weak claiming isn't yet delivering what you bought — you've funded the protection without unlocking it.
And employees do eventually draw conclusions, though not in a way that shows up in your engagement survey. It surfaces the following year as an election they don't renew, or as a quieter belief that supplemental coverage isn't worth much. That belief is expensive and slow to reverse, and it's unfair to a category that works well when it's actually used.
Two questions worth putting to your carrier or broker before your window opens.
What's our claims rate against our election rate? Not dollars paid. The share of enrolled employees who filed anything at all in the last twelve months. If nobody can produce that number quickly, that's information too.
Which covered triggers have never generated a single claim in our population? A rider category with zero claims across thousands of employees isn't evidence that nothing happened. It's evidence that nobody connected the two.
This is where we'd usually tell you to improve your enrollment materials. We're not going to, because the finding above says communication isn't the constraint. The gap appeared in all six populations, including ones with well-resourced benefits teams and strong screening participation. Employees were completing the screenings. More explaining doesn't close a gap that explaining didn't create.
What closes it is connecting two systems that were never built to talk to each other: the one that knows what happened to an employee, and the one that knows what they're covered for.
That's what Nayya Claims does. We receive medical claims data, match it against the employee's supplemental coverage to identify payout opportunities, and then either notify the employee with the claim already started or, where we're integrated with the carrier, file it on their behalf. The employee confirms a few details and gets paid directly by their carrier. They never have to recognize the trigger, hunt for the rider, or remember a deadline, because the match already happened.
On your side, it's one signed Employer Authorization Form instructing your TPA to share medical claims with our data warehouse. No IT project, no ongoing lift from your team. We handle the carrier and TPA agreements, and you can expect real financial impact for employees within six months.
On privacy, because you'll be asked: we're HIPAA compliant and SOC2 + HITRUST certified. Claims data is used to find an employee's own reimbursement opportunities and nothing else. Employers can't see individual employee health data.
Nobody withheld anything here. Employees paid their premiums. Carriers stood ready to pay valid claims. HR teams communicated the coverage.
The gap is structural. The system that collects the premium and the system that pays the claim were never designed to talk to each other on the employee's behalf, so the work of connecting them fell to the person least equipped to do it — the employee, often while recovering from the thing that qualified them in the first place.
The encouraging part is that it's a findable problem. We found 17,142 of them in six populations, and we found them by looking in places that were already there. The triggers are in the claims data. The coverage is written into the riders. The screenings already happened.
You fought to get this coverage in place. This is the year to make sure it pays out.
