Claim decision and benefit settlement

Step by step

1. Report loss Claims Examiner

   Claims Examiner records the policy, loss date, reported date, claimed amount and evidence.

   • Identify covered policy and loss
   • Updates Claims, Policies

2. Assess cover Claims Examiner

   Claims Examiner checks dated coverage, exclusions, limits, deductible and prior verified payments.

   • Check applicable terms and paid scope
   • Updates Policy coverages, Claims, Claim payments

3. Decide benefit Authorized Underwriter

   Authorized Underwriter records Approve, Decline or request evidence with reason and benefit amount.

   • Record authorized result
   • Updates Claim decisions, Claims
   ApprovalA person approves before the work moves on.

4. Confirm payment Authorized Underwriter

   Authorized Underwriter compares provider event evidence and verified payments with the approved amount.

   • Check verified amount and event
   • Updates Claim payments, Claim decisions

5. Settle claim Claims Examiner

   Claims Examiner follows the claim status and operation receipt after confirmed payment.

   • Reconcile paid effect and status
   • Updates Claims, Operation receipts

Claims Examiner

Prepares the loss assessment.

Authorized Underwriter

Records the insurer decision and reconciles payment.

Auditor

Reads the result.