Corporate (Group) health Insurance

1. MODULE OVERVIEW.....................................................................................1
Module Name.............................................................................................1
Purpose......................................................................................................1
Scope.........................................................................................................1
High-Level Objectives................................................................................1
USE CASE 1: Upload & Validate Employee Census.......................................2
Use Case ID................................................................................................2
Use Case Name..........................................................................................2
Actors.........................................................................................................2
Description.................................................................................................2
Preconditions.............................................................................................2
Postconditions / Expected Outcome...........................................................2
Screen / UI Requirements..........................................................................3
Screen Name...........................................................................................3
Purpose / Description..............................................................................3
Fields / Elements.....................................................................................3
Business Rules (Validation)........................................................................3
Assumptions...............................................................................................3
Dependencies............................................................................................4
USE CASE 2 – Derive Age Risk Flag..................................................................4
Use Case ID...................................................................................................4
Use Case Name.............................................................................................4
Actors............................................................................................................4
Description....................................................................................................4
Preconditions................................................................................................5
Postconditions / Expected Output.................................................................5
Business Rules..............................................................................................5
 Output........................................................................................................5
Assumptions...............................................................................................5
Dependencies............................................................................................6
USE CASE 3 – Derive Dependent Risk Flag......................................................6
Use Case ID...................................................................................................6
Use Case Name.............................................................................................6
Actors............................................................................................................6
Description....................................................................................................6
Preconditions................................................................................................7
Postconditions / Expected Output.................................................................7
Business Rules...........................................................................................7
Rule 1: Risk Indicator Based on Maximum Dependent Age.......................7
Rule 2: Risk Indicator Based on Dependent Count.....................................7
Rule 3: Final Dependent Risk Resolution....................................................7
Output........................................................................................................8
Assumptions...............................................................................................8
Dependencies............................................................................................8
USE CASE 4 – Capture & Map Work Risk Flag..................................................8
Use Case ID...................................................................................................8
Use Case Name.............................................................................................8
Actors............................................................................................................9
Description....................................................................................................9
Preconditions................................................................................................9
Postconditions / Expected Output.................................................................9
Business Rules..............................................................................................9
Assumptions.............................................................................................10
Dependencies..........................................................................................10
USE CASE 5 – MAX Risk Gate Check..............................................................10
Use Case ID.................................................................................................10
Use Case Name...........................................................................................10
 Actors..........................................................................................................10
Description..................................................................................................10
Postconditions / Expected Output...............................................................11
Business Rules............................................................................................11
Risk Priority Order (Precondition).............................................................11
Assumptions.............................................................................................12
Dependencies..........................................................................................12
USE CASE 6 – Final Risk Escalation & Employee Risk Classification...............12
Use Case ID.................................................................................................12
Use Case Name...........................................................................................12
Actors..........................................................................................................12
Description..................................................................................................12
Preconditions..............................................................................................13
Postconditions / Expected Output...............................................................13
Business Rules............................................................................................13
Risk Levels Considered............................................................................13
Escalation Rules (Final Risk Determination).............................................14
Business Rule 1.....................................................................................14
Business Rule 2.....................................................................................14
Business Rule 3.....................................................................................14
Business Rule 4.....................................................................................14
Assumptions.............................................................................................14
Dependencies..........................................................................................14
USE CASE 7 – Aggregate Employees by Final Risk Category.........................15
Use Case ID.................................................................................................15
Use Case Name...........................................................................................15
Actors..........................................................................................................15
Description..................................................................................................15
Preconditions..............................................................................................15
Postconditions / Expected Output...............................................................16
 Business Rules............................................................................................16
Risk Categories Considered.....................................................................16
Aggregation Rule.....................................................................................16
Assumptions.............................................................................................16
Dependencies..........................................................................................16

Business Requirement Document

1. MODULE OVERVIEW

Module Name

 Employee Census & Risk Data Management

Purpose

 To ingest employee census data from corporate HR, validate

employee and dependent details, classify employees into
risk categories using predefined business rules, and provide
aggregated risk counts to the underwriting module for
premium calculation.

Scope

This module includes:

 Uploading employee census Excel files

 Validating employee, dependent, and work-risk data
 Returning validation results in JSON format
 Deriving age, dependent, and work-based risk flags
 Determining final employee risk category
 Aggregating employees by risk category
High-Level Objectives

 Ensure accurate and clean employee data

 Apply deterministic, explainable risk rules
 Support underwriting with aggregated risk statistics
 Provide transparent validation feedback to HR

2. USE CASE DETAILS

USE CASE 1: Upload & Validate Employee Census

Use Case ID

 UC-M2-01

Use Case Name

 Upload and Validate Employee Census File

Actors

 Corporate HR
 System

Description

 HR uploads an Excel file containing employee demographic

details, dependent data, and work risk classification. The
system validates each employee record and separates valid
and invalid records.

Preconditions

 Corporate proposal Should exists and also corporate ID.

 HR has finalized employee census data.
Postconditions / Expected Outcome

 Valid employee records are accepted.

 Invalid records are rejected with clear error messages.
 Validation result is returned in JSON format.

Screen / UI Requirements

Screen Name

 Employee Census Upload & Validation.

Purpose / Description

 Allows HR to upload census file and view validation results.

Fields / Elements

Field Type Mandator Validation Comments

Name y
Upload file File Yes .xls/.xlsx The file type
only to upload
Upload Button Yes - Triggers
Button Validation
Validation JSON view yes - Shows
Result valid /invalid
employee
data

Business Rules (Validation)

 Employee ID must be unique.

 Employee Age must be between 18 and 65.
 Work-Risk must be Normal / Risk / High Risk.
Assumptions

 Corporate HR provides the employee census file in the

prescribed Excel format.
 Employee census data is approved internally by the
company before upload.
 Employee identifiers are unique within the uploaded file.
 Age, dependent count, and work risk data are entered
correctly by HR.
 File size and format limitations are communicated to HR in
advance.

Dependencies

 Corporate profile and insurance proposal must exist before

census upload.
 File upload and Excel parsing services must be available.
 Validation rules (age limits, allowed work risk values) must
be configured.
 Error messaging standards must be defined for validation
responses.
 System must support JSON-based validation responses.

USE CASE 2 – Derive Age Risk Flag

Use Case ID

 UC-M2-02

Use Case Name

 Derive Age Risk Flag for Valid Employees

Actors

 System (Risk Rules Engine)

Description

 This use case derives an age-based risk flag for each

validated employee record based on predefined age
bands.
The derived age risk flag is used as an input for final
employee risk classification.

Preconditions

 Employee census file has been successfully uploaded

 Employee records have been validated in Use Case 1
 Employee age is present and within valid range (18–65)
 Only valid employee records are processed

Postconditions / Expected Output

 Each validated employee record is updated with:

age_risk_flag.
 Possible values:
 Normal
 Risk
 High_Risk
 No employee records are rejected in this step

Business Rules

Employee Age Age Risk Flag

18 – 33 Normal
34 – 50 Risk
> 50 High_Risk
Output

 age_risk_flag added to employee record

Assumptions

 Employee age provided in the census file is accurate and

verified by HR.
 Age is calculated and stored as a numeric value (years).
 Age bands are approved by the underwriting team.
 Age values do not change during the underwriting process.

Dependencies

 Successful completion of Use Case 1 (Upload & Validate

Employee Census).
 Employee age must be present and within the valid range.
 Risk band configuration for age must be available in the
system.

USE CASE 3 – Derive Dependent Risk Flag

Use Case ID

 UC-M2-03

Use Case Name

 Derive Dependent Risk Flag for Valid Employees

Actors

 System (Risk Rules Engine)

Description

 This use case derives a dependent-based risk flag for

each validated employee record using maximum
dependent age and dependent count.
 The derived dependent risk flag is used as an input for final
employee risk classification.

Preconditions

 Employee census data has been uploaded and validated

(Use Case 1)
 Employee record is marked as valid
 dependent_count is available
 max_dependent_age is available (or zero if no dependents).

Postconditions / Expected Output

 Each validated employee record is updated
with:dependent_risk_flag
 Possible values:
 Normal
 Risk
 High_Risk
 No employee records are rejected in this step

Business Rules

Rule 1: Risk Indicator Based on Maximum Dependent Age

Max Dependent Risk Indicator

Age
0 – 34 Normal
35 – 50 Risk
> 50 High_Risk
Rule 2: Risk Indicator Based on Dependent Count

Dependent Count Risk

Indicator
0–1 Normal
2–3 Risk
4+ High_Risk

Rule 3: Final Dependent Risk Resolution

Risk Indicator Final Dependent Risk Flag

Count
0 Risk Normal
1 Risk Risk
2 Risks High_Risk
High_risk High_Risk

Output

 dependent_risk_flag added to employee record

Assumptions

 HR provides accurate dependent count and dependent age

information.
 Maximum dependent age correctly represents overall
dependent risk.
 Dependent risk rules are approved by underwriting.

Dependencies

 Successful completion of Use Case 1 (Employee

Validation).
 Availability of dependent count and maximum dependent
age.
 Risk thresholds must be configured in the system.
USE CASE 4 – Capture & Map Work Risk Flag

Use Case ID

UC-M2-04

Use Case Name

Capture and Map Work Risk Flag from HR Census File

Actors

 Corporate HR
 System (Risk Rules Engine)

Description

 This use case captures the nature of work risk provided

directly by HR in the employee census file and maps it to the
internal work risk flag.
 No additional calculation or inference is performed in this
step.

Preconditions
 Employee census file has been successfully uploaded and
validated (Use Case 1)
 Employee record is marked as valid
 work_risk field is present in the uploaded file
 work_risk value conforms to predefined allowed values
Postconditions / Expected Output
 Each validated employee record is updated
with:work_risk_flag
 Possible values:
 Normal
 Risk
 High_Risk
 No employee records are rejected in this step

Business Rules
HR Input Value work_risk_flag
Normal Normal
Risk Risk
High Risk High_Risk

Assumptions

 Work risk classification is provided accurately by HR.

 HR-defined work risk reflects real job exposure.
 Work risk values are standardized across the organization.

Dependencies

 Successful completion of Use Case 1 (Employee

Validation).
 Availability of allowed work risk values in configuration.

USE CASE 5 – MAX Risk Gate Check

Use Case ID

 UC-M2-05
Use Case Name

 Evaluate Maximum Risk Flag (Risk Gate Check)

Actors

 System (Risk Rules Engine)

Description

 This use case evaluates whether an employee has any risk

at all by identifying the maximum risk flag among age
risk, dependent risk, and work risk.
 It acts as a gate to decide whether escalation logic is
required or the employee can be directly classified as
Normal risk.

Postconditions / Expected Output

 Employee is either:
 Directly classified as Normal, or
 Flagged for escalation processing in Use Case 6
 No employee records are rejected in this step

Business Rules

Risk Priority Order (Precondition)

 The system must follow the below risk severity hierarchy:

Normal < Risk < High_Risk

MAX Risk Gate Rule

 The system identifies the maximum risk flag among:

 age_risk_flag
  dependent_risk_flag
 work_risk_flag

 If: MAX(age_risk_flag, dependent_risk_flag,

work_risk_flag) = Normal
 Then:
 final_risk_category = Normal
 and no further escalation logic is applied.

 If: MAX(age_risk_flag, dependent_risk_flag,

work_risk_flag) = Risk OR High_Risk

 Then:
 Proceed to Use Case 6 – Final Risk Escalation

Assumptions

 Risk priority order is fixed and consistently applied

 All base risk flags are present and valid
 MAX evaluation is deterministic and rule-based

Dependencies

 Successful completion of Use Cases 2, 3, and 4

 Availability of risk priority configuration
 Final risk escalation logic available in Use Case 6

USE CASE 6 – Final Risk Escalation & Employee Risk

Classification

Use Case ID

 UC-M2-06
Use Case Name

 Determine Final Employee Risk Category (Escalation Logic)

Actors

 System (Risk Rules Engine)

Description

 This use case determines the final employee risk

category by applying escalation logic on the derived risk
flags (age risk, dependent risk, and work risk).
 It is executed only for employees who pass the MAX
Risk Gate in Use Case 5.

Preconditions

 Employee census data has been uploaded and validated

(Use Case 1)
 age_risk_flag is available (Use Case 2)
 dependent_risk_flag is available (Use Case 3)
 work_risk_flag is available (Use Case 4)
 Employee has been flagged for escalation
(escalation_required = true) in Use Case 5

Postconditions / Expected Output

 Each employee record is updated

with:final_risk_category
 Possible values:
 Normal
 Risk
 High_Risk
 Very_High_Risk
  Employee record is ready for aggregation in Use Case 7

Business Rules

Risk Levels Considered

 Each employee has three base risk flags:

 Normal
 Risk
 High_Risk

Escalation Rules (Final Risk Determination)

 The system counts how many risk flags fall under Risk and
High_Risk.

Business Rule 1

 If two or more High_Risk flags are present:

 Final Risk Category = Very_High_Risk

Business Rule 2

 If exactly one High_Risk flag is present:

 Final Risk Category = High_Risk

Business Rule 3

 If two or more Risk flags are present:

 Final Risk Category = High_Risk

Business Rule 4

 If exactly one Risk flag is present:

 Final Risk Category = Risk
Assumptions

 Risk escalation rules are approved by underwriting

 Risk flags are mutually exclusive and correctly derived
 Escalation logic is deterministic and rule-based

Dependencies

 Successful completion of Use Case 5 (MAX Risk Gate)

 Availability of risk flag data
 Configuration for escalation thresholds

USE CASE 7 – Aggregate Employees by Final Risk Category

Use Case ID

 UC-M2-07

Use Case Name

 Aggregate Employee Counts by Risk Category

Actors

 System (Risk Rules Engine)

 Underwriting Module (Module 3 – Consumer)

Description

 This use case aggregates employees into risk buckets

based on the final_risk_category derived in Use Case 5
and Use Case 6.
 The aggregated counts are passed to the Underwriting
Module (Module 3) for premium calculation.
Preconditions

 Employee census data has been uploaded and validated

(Use Case 1)
 final_risk_category is available for all employees
 Normal employees classified in Use Case 5
 Risk / High / Very High employees classified in Use
Case 6
 No employee record is left unclassified

Postconditions / Expected Output

 Aggregated employee counts are generated

 Output is structured and ready for premium calculation
 No individual employee data is sent beyond this point

Business Rules

Risk Categories Considered

 The system aggregates employees into the following

categories:
 Normal
 Risk
 High_Risk
 Very_High_Risk

Aggregation Rule

 For each employee:

 Increment the counter corresponding to the employee’s
final_risk_category
 No recalculation or escalation is performed in this step.
Assumptions

 Every employee record has a valid final_risk_category

 Risk categories are mutually exclusive
 Aggregated counts are sufficient for underwriting decisions

Dependencies

 Successful completion of Use Case 5 and Use Case 6

 Availability of all employee risk classifications
 Underwriting Module (Module 3) is available to consume
aggregated data