Exploring Insurance claims
Learn how to create and configure a claims workflow for your organization by using the Insurance claims application. Your first notice of loss (FNOL) representatives, adjusters, processors, and managers can use this claims workflow to create and manage claims.
Insurance claims overview
With the Insurance claims application, you can easily set up an entire claims process for a single policy use case under property and casualty (P&C) lines of business. The Insurance claims application provides a claims framework that you can use for multiple lines of business.
A travel insurance claim flow is included with this application as an example.
Insurance claims users
| User | Description |
|---|---|
| Administrator | Claims administrators are responsible for configuring the Insurance claims application. They set up the service definitions, product models, policies for personal and commercial products, and tables to record information on claims incidents. They can also set up the claim incident configuration for a new line-of-business claims flow or to update an existing configuration. |
| FNOL representative | FNOL representatives are front-office staff who create a claim case on behalf of a customer and upload the relevant documents. |
| Claims adjuster | Claims adjusters are middle or back-office staff that work on adjuster tasks to evaluate claims, approve reserve and payment amounts, and settle payments. |
| Claims processor | Claims processors are middle or back-office staff that own cases. They create claim tasks for adjusters, track adjuster tasks to ensure they're worked to completion, and add additional tasks as required. |
| Claims manager | Claims managers are middle or back-office staff that authorize the reserve and amounts that require additional approval. They also monitor staff performance with dashboards and metrics. |
Insurance claims workflow
Here's a typical workflow for an insurance claim in the Insurance claims framework.
Image omitted: insurance-claims-workflow.png
Infographic that shows a typical workflow for an insurance claim. For the text description, refer to the steps that follow.
Infographic that shows a typical workflow for an insurance claim. For the text description, refer to the steps that follow.
- A customer reports a claim.
- The FNOL representative, in the claim intake playbook, selects the claim type, the policy, the claim participants, and the incident details. If applicable, they add any itemized losses and supporting documentation provided by the customer.
- The claim is submitted and assigned to a claims specialist or adjuster.
- The claims specialist or adjuster reviews the policy details and requests additional information from the customer if necessary.
- The claims specialist or adjuster sets the reserve funds and payments, modifies the coverage exposures and reserve funds over time, and monitors the claim handling activity.
- If the reserve or payment amounts are above the adjuster's approval limit, an approval task is generated for the claims manager, who approves or rejects the amount.
- The claims specialist or adjuster makes the claim approval or denial decisions based on the provided evidence, and the workflow ends.
Benefits of the Insurance claims application framework
| Benefit | Feature | Users |
|---|---|---|
| Versatile framework that adapts to any single policy P&C claims without the need to create case types or flows | Using Insurance claims | Claims administrators, FNOL representatives, claims processors, claims adjusters, or claims managers |
| Rapid configuration that enables the setup of a comprehensive end-to-end claims workflow quickly and easily | Setting up Insurance claims | Claims administrators |
| Support for single and multiple adjusters | Work on Insurance claims adjuster tasks | Claims adjusters or claims managers |
| Customizable persona-based workspaces to fit specific roles and responsibilities | Insurance claims landing pages and workspaces | Claims administrators, FNOL representatives, claims processors, claims adjusters, or claims managers |
What to explore next
To learn more about configuring and using Insurance claims, see: