Claims and decisions

Trace a reported loss from policy and loss date to a reasoned insurer decision. A claim starts with its claim number, policy, loss date, report date, amount and loss evidence. The loss date matters because coverage lines have effective windows, exclusions, limits and deductibles. The examiner checks those terms and any earlier verified payments before presenting a benefit recommendation. The claim status tracks assessment and review without standing in for the decision record.

• Report. Claims Examiner records the policy, loss date, claimed amount and loss evidence.
• Assess. Claims Examiner compares the loss date with coverage windows, exclusions, limits, deductible and verified prior payments.
• Decide. Authorized Underwriter records the insurer decision, reason and approved benefit before payment is considered.

The insurer decision carries its own decision date, authorized-by value, reason and approved benefit amount. An approval is distinct from a payment. A decline needs a reason that can be read with the reported loss. If more evidence is requested, the request and later decision remain tied to the same claim.

Read the claim and applicable policy terms together before recording a benefit. The claim’s status describes its progress; the separate insurer decision gives the authorized result and reason. A request for more evidence leaves the loss open for review. A claim marked approved still needs verified payment evidence before settlement.

Agree who is authorized to assess and decide each organization’s claims. Define the evidence expected for loss, the treatment of exclusions and prior paid scope, and how the approved benefit is calculated. Keep the decision and claim status aligned while preserving each record’s separate purpose.

For a reported loss near a coverage change, the examiner opens the claim and checks the loss date against the earlier and later coverage windows. The underwriter reviews the applicable limit, deductible and exclusion, then records the decision and reason. If approved, payment processing still needs confirmed evidence before the claim is treated as settled. The claim number, policy and decision remain available for later review.

• Claims for assessment — Shows reported losses being evaluated or reviewed.
• Approved claims awaiting settlement — Shows decided claims that need payment follow-up.

Follow claim decision and benefit settlement, then check the data model for the claim, decision and payment references.