Claims and settlement

The loss claim holds a claim number, loss date, report date, claimed amount, evidence and policy link. The Insurance Coordinator identifies the event against an exact policy before assessment. The reviewer compares coverage effective at the loss date, including limits, deductible and exclusions. That comparison informs the decision but does not replace the authorized insurer’s determination.

The insurer decision records its date, approve or decline or request-evidence result, approved benefit, reason and authorizing identity. A separate payment record holds amount, payment date, provider event ID and verification status, linked to both the claim and decision. A claim can be approved while payment is still unresolved. Staff should use the verified payment record when answering whether the payout happened.

• Loss context. Record the claim number, policy, loss date and evidence.
• Authority. Keep the insurer’s result, amount and reason in a decision record.
• Settlement. Reconcile each payment to its decision and provider event.

Agree who records the insurer’s decision, how evidence requests return to the coordinator and which provider event proves payment. Decide how partial or repeated payments will be reconciled against the approved benefit. The team also needs a rule for claim closure after the payment evidence is checked. If adjudication and payout happen in carrier systems, connect those sources and assign an owner to verify their results.

Take a loss reported after a policy endorsement. The effective coverage at the loss date may be different from today’s coverage. The underwriter should be able to explain which line applied before recording a benefit amount. A later provider callback with the same event ID should be recognized as the same payment evidence.

Open a reported claim and follow its policy, loss date and coverage lines. Compare the claimed amount with the authorized decision and reason. Then open the payment linked to that same claim and decision; check the amount, paid date, provider event and verification value. Have the Auditor trace the full path without editing it. If payment is unverified, leave settlement unresolved until the provider result can be reconciled.

• Claims In Assessment — Inspect reported and review-stage losses with their policy links.
• Verified Claim Payments — Reconcile paid amounts and provider events with decisions.

Follow policy setup and claim review as the record moves from preparation to a decision. Use the data model to map each handoff to its parent record.