Claims Operations & Settlement

Overview of Claim Settlement

Claim settlement is the step in the claim processing where the adjuster based on the claim inputs and business rules decides the settlement offer for the insurer either manually or helped though multiple automated actions. During this step, there is a high possibility of communication with the insured.

During the claim settlement step, adjusters can initiate a subrogation, litigation, recovery initiation, field inspection, payment plan, etc.

The claim settlement steps vary for different lines of businesses.

Claims FNoL is one of the many applications offered as part of Appcino's Insurance Claims operation Suite. Each of the provided applications can be deployed independently or in combination with other applications as per the requirements & use cases. This application follows standard insurance practices and is easy to integrate with any Appian application OR external existing claims systems.

Targeted Market Challenges

• Poor Efficiency - With high volumes of claims coming daily, it is a challenge for insurers to assign the right cases to the experienced adjuster based on the claim complexity and skills to ensure the claim gets settled in minimum time. The incorrect assignment leads to the frequent reassigning of the claim to different people in the team, which further adds to the total settlement time, therefore reducing efficiency.
• Lack of claims approvals - decision rules and automation also requires adjusters to invest time on the claim that looks simple & easy to approve - resulting in focusing time on less complicated claims.
• Lack of unified claims view - Adjusters have to access multiple disconnected systems to look for claim information resulting in many systems switches, therefore, increasing the settlement time and inaccurate settlement leading to revenue loss for Insurers. It also results in different stakeholders looking at incomplete claims information.
• Incorrect & Limited Data Point - Many times, the claim adjusters have no direct & easy way to enrich claim information and to request any additional/ supporting documents from customers or internally, which results from accessing inaccurate details for every user accessing the claim.
• Lack of Agility - Many times, the insurers are required to make changes to the settlement process based on the regulatory requirements or an outcome of the internal assessment to improve the process.

Key Features

• Dynamic Case Management - Instead of manually deciding the next steps, determine the workflow yourself, and automate your claims journey. Initiate a new litigation case, subrogation case, and field inspection directly from the claims record.
• Claim Lifecycle Management - Enrichment, activity management, add/ assign activity, claim diary, reassignment, closure, Ad-hoc closure, and reopening.
• Business Rules - Business rules for policy coverage identification, Claims assignment matrix, Claim complexity evaluation, Assign cases based on the Adjuster competency and skills
• Vendor Management - Integrate with vendor system and address book, Vendor management, payment management with history
• Reserves & Payment Management - Rule-based or manual reserve allocation, Reserves management, request reserve increase with authorization and notification limits, Payment authorization and payment management
• Settlement Module - Specialized settlement specific to LoB's, Communication module (email, char, etc.), Settlement documents management
• Third-Party & Negligence - Enrich the third party at any stage of a claim, Manage negligence percentage of each third party, Automatic subrogation initiation, Manage third party insurance details