claims processing flow

INSURANCE PROCESS FLOW PPT CLAIMS

Claim Intimation By Claimant

Accept Intimation And Do Policy Enquiry

Validate Claim Against Policy

Is Policy In Force

Y/N?

Decline Claim AndInform Claimant

A

A

Claim Survey Process

IsReinsurance Applicable

Y/N?

Claim Processing Flow DiagramStart

Claim Assignment

Reinsurance(clm)

Is ClaimValid Y/N?

Stop

Decline Claim andInform Claimant

N

Stop

Is ClaimValid Y/N?

Determine EstimatesAuthorize & Update Reserves

Y

IsCash call Limit <Claim Reserve/

Estimate?

Loss Advice To Reinsurer

B

B

Reinsurance processto check whetherto get amount from reinsurer before settlementdue to cash call limit


N

N

Y

Y

Y

N

N

Y

Recovery Process

IsRecoveryPossible

Y/N?

Close Claim

Stop

B

Prepare Discharge & Release Documents

Intimate Client & GetAcceptance

DoesClient Accept

Y/N?

Claim Settlement

Litigation

C

C

Reinsurance(Clm)

Y

Claim Processing Flow Diagram

ClaimantWinsY/N?

N

Y N

IsCash Call Limit >

Claim Reserve/Estimate

Reinsurance processto get amount from reinsurer after settlement


IsReinsurance Applicable

Y/N?

Y

N

Y

N

Policy

Reserves

Occurrence

Claim Coverage

ClaimClaimant(s)

Payments

LitigationRecoveries

Claims Processing Entity Relationship Diagram

Role

1 1

n

1

n 1 1

1

n

1

n

1 nn 1

1 1

1n

Reserves

1

n

assign

checkReinsurer

intimate1

n

make linked

consist

can leadcan have

settle update

validate

1

consist


Claim Processing

Claim Survey 2.0

Claim Recording1.0

Claim Settlement3.0

Claim Intimation 1.1

Claim Assignment 1.2

Claim Recording 1.3

AssignSurveyors 2.1

Conduct Survey 2.2

Claim AmtEstimation 3.1

Reinsurance Data 3.2

Payments 3.3

Reporting 3.4

Claims Processing Process Chart


Client/Claimant

Claim Recording1.0

UnderwritingSection

Reserve_data

Policy_data

Logical Data Flow Diagram of Claims Recording

Agent/Broker Agent_data

Client_data

Claim_data

Claim Intimation

ClaimStatus

Claim Intimation

Ack/Declineclaim

Underwriting clauses

Store Claim data

Agent Information

Client Information

Claim Reserve amt

Policy Validation


Claim Intimation& Enquiry

1.1

Claim Recording

& Validation1.3

Agent/Broker

Client/claimant

Underwriting Section

Policy_dataAgent_data Client_data

Reserve_data

Claims_data

Claims Recording - II Level Data Flow Diagram

Claim Assignment

1.2

ClaimStatus

Claim Intimation

AckDecline/Accept Claim

UnderwritingClauses

Agent_data, Client_data, Policy_data are used for claim validation

ClientInfoAgent Info

Claim Reserve Amt

Policy Info


Claim Survey2.0

UnderwritingSection

Policy_data

Logical Data Flow Diagram of Claims Survey

Agent_data

Client_data

Claim_data


Agent Information

Client Information

Policy Validation

Reserve_dataReserve data info

Claim data for reference

Survey_dataSurvey data

Survey help

Surveyor_data

MVR/MIB

Reqforinfo

Reqinfo

Surveyor data

Updatesurvey info

Survey Section

ReinsurerClaim Int.Acknowledge

ClaimantDischarge & Rel Doc

Acceptance/Rejection


Assign Claim surveyors

2.1

ConductSurvey

2.2

Surveyor_data

Surveyor data

Claim_data


UpdateSurveyor

Survey help

Survey_data

Surveydata

UnderwritingSection


Agent_data Client_data Policy_data Reserve_data

Agent_data, Client_data, Policy_data and Reserve_data are used for validation

Claims Survey - II Level Data Flow Diagram

Survey Section

MVR/MIBInfo request

Report

ReinsurerClaim int

Ack/pay.

Update statusLitigation

ClaimantDoc


Claim Settlement3.0

UnderwritingSection

Policy_data

Logical Data Flow Diagram of Claims Settlement

Agent_data

Client_data

Claim_data

Agent information

Client information

Policy validation

Reserve_dataReserve data info


Survey_data Survey data

ReinsurerReinsured claim amount

Update claim status

Payment transaction

Reports

Clearing HouseACH

Management

Paymentdetail

Reports

Update reserve

Agent

Client

Payment info

Payment info

Accounts

State Gov/Legal Org.Reports


Claim AmtEstimation

3.1

Reinsurance Data3.2

Payments3.3

Reporting3.4

Survey_dataSurvey info

ManagementACH

UnderwritingSection

Reports

Reports

Payment infoPayment info

Reinsurer

Reinsurance data

Claim_data Agent_data Client_data

Client Agent

Payment info

Reserve_data Policy_data

Reservedata

Agent_data, Client_data, Policy_data and Reserve_data are used for validation

Claims Settlement - II Level Data Flow Diagram

Update approx lossamt

Policy data

Accounts
