Breaking down the claims handling process

Despite a lack of industry standards when it comes to claims handling, insurers do tend to follow a de facto pattern in how their claims handling teams work. The key areas that these teams are responsible for are most often identified as:

FNOL: The first notice of loss is the moment that the customer registers a claim with the insurer.
Claim updates: The customer seeks information about the claim, or has additional information to provide to the insurer about the claim.
Policy analysis: The claims handler analyzes the policy to understand the applicable coverage and exclusions.
Claim circumstances: The claims handler builds a picture of what happened in the incident leading to the claim, identifying characteristics that are important from an insurance point of view (such as liability).
Document analysis: The claims handler validates documents that are provided by the insured.
Loss estimation: The claims handler uses his or her knowledge, tools or the advice of an expert to generate an estimate of the loss.
Coverage decision: The claims handler applies the policy to the circumstances in order to make a decision about whether the claim is covered.
Fraud decision: The claims handler asks for clarification from the claimant, or refers suspicious claims to the SIU.
Resolution decision: The claims handler applies business policy and their judgment to decide what type of proposal(s) to offer the customer.

The interesting thing is that these tasks — as heterogeneous and complex as they are — all fall under the responsibility of the claims handling team. In many insurance companies, a single person is capable of accomplishing them all. Hence, we can think of claims automation as the challenge of building an AI claims handler. This goes far beyond Robotic Process Automation (RPA) or automating a single task.

Special Reports /

Creating an AI claims handler

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