INSURANCE PROCESS FLOW PPT CLAIMS

Claim Processing Flow Diagram

Start A

Claim Intimation By Is Claim N

Claimant Valid
Y/N? Decline Claim and
Accept Intimation And
Reinsurance process Y Inform Claimant
Do Policy Enquiry to check whether
Determine Estimates
to get amount from Authorize & Update Reserves Stop
reinsurer before settlement
Claim Assignment due to cash call limit
Is
Reinsurance N
B
Is Policy N Applicable
Decline Claim And
In Force Y/N?
Inform Claimant
Y/N?
Y
Y N Stop
Validate Claim Against Is
Is Claim N Loss Advice To
Policy Cash call Limit <
Valid Y/N? Reinsurer
Claim Reserve/
Y Estimate?
Claim Survey Process
Y

A Reinsurance(clm) B

INSURANCE PROCESS FLOW PPT CLAIMS

 Claim Processing Flow Diagram
C
B Reinsurance process
to get amount from
reinsurer after Is
settlement Reinsurance
Prepare Discharge &
Applicable
Release Documents
Y/N?

Intimate Client & Get Is Y

Acceptance Cash Call Limit > Reinsurance(Clm)
Claim Reserve/
Estimate

Does N N
Client Accept Litigation
Y/N? Is
Recovery Y
Recovery
Y Possible Process
Claimant Y/N?
Y N
Claim Settlement Wins
N
Y/N?
Close Claim

C
Stop

INSURANCE PROCESS FLOW PPT CLAIMS

 Claims Processing Entity Relationship Diagram
n
Policy Role
1
validate assign n
n Reinsurer
Reserves check
intimate
1 1 1 1
n 1 1 1 Occurrence
make linked
Claimant(s) Claim

1 1
consist consist
n n
n 1 Claim 1 n Litigation
Recoveries can have can lead
Coverage
1 1
settle update
1
n
Reserves
Payments

INSURANCE PROCESS FLOW PPT CLAIMS

 Claims Processing Process Chart

Claim Processing

Claim Recording Claim Survey Claim Settlement

1.0 2.0 3.0

Claim Claim Assign Conduct Claim Amt Reinsurance

Intimation Recording Surveyors Survey Estimation Data
1.1 1.3 2.1 2.2 3.1 3.2

Claim Payments Reporting

Assignment 3.3 3.4
1.2

INSURANCE PROCESS FLOW PPT CLAIMS

 Logical Data Flow Diagram of Claims Recording

Agent Information
Agent/Broker Agent_data

Claim Claim Claim

Intimation Status Intimation Client Information
Client/Claimant Client_data
Ack/Decline
claim

Claim Recording Claim Reserve amt

1.0 Reserve_data

Underwriting clauses Policy Validation

Policy_data
Underwriting Store Claim data
Section
Claim_data

INSURANCE PROCESS FLOW PPT CLAIMS

 Claims Recording - II Level Data Flow Diagram

Underwriting
Reserve_data Clauses Underwriting
Claim
Agent/Broker Section
Intimation Claim
Claim Reserve
Status Claim Amt Claim
Intimation Claim
Recording
& Enquiry Assignment
& Validation Claims_data
Client/claimant Ack 1.1 1.2
1.3
Decline/
Accept
Claim

Client Policy
Agent Info Info Info

Agent_data Client_data Policy_data

Agent_data, Client_data, Policy_data are used for claim validation

INSURANCE PROCESS FLOW PPT CLAIMS

 Logical Data Flow Diagram of Claims Survey

MVR/MIB Agent Information

Agent_data
Survey Section Survey help
Req Req
for info Client Information
Surveyor data info Client_data
Surveyor_data
Reserve data info
Reserve_data
Survey data Claim Survey Acceptance/Rejection
Survey_data 2.0

Claim Int. Discharge & Rel Doc Claimant

Reinsurer Acknowledge
Policy Validation
Underwriting clauses Policy_data
Claim data for reference
Underwriting Update
Section survey
info Claim_data

INSURANCE PROCESS FLOW PPT CLAIMS

 Claims Survey - II Level Data Flow Diagram

Update
Surveyor Survey Section
Claim_data
Surveyor_data
Claim data for reference Survey help
MVR/MIB
Surveyor data Info request
Update status Report
Assign Claim Litigation Conduct
Survey Claim int
surveyors Reinsurer
2.1 2.2
Ack/pay.
Survey
data Doc
Underwriting Underwriting clauses Claimant
Section

Agent_data Client_data Survey_data Policy_data Reserve_data

Agent_data, Client_data, Policy_data and Reserve_data are used for validation

INSURANCE PROCESS FLOW PPT CLAIMS

 Logical Data Flow Diagram of Claims Settlement

Reinsured claim amount Agent information

Reinsurer Agent_data

Client information
Agent Payment info Client_data
Payment Payment info
Client
transaction
Accounts
Reserve data info
Reserve_data
Survey_data Survey data Claim Settlement
3.0 Update reserve

Underwriting Reports Policy_data

Section Policy validation
Reports
Clearing House Update claim Management
status Claim data for reference
ACH Payment
detail Claim_data
State Gov/
Reports Legal Org.

INSURANCE PROCESS FLOW PPT CLAIMS

 Claims Settlement - II Level Data Flow Diagram

Reinsurer Accounts ACH Management

Survey info
Survey_data
Reinsurance Payment Payment info
data Reports
info
Claim Amt Reinsurance
Update Data Payments Reporting
Estimation
approx loss 3.2 3.3 3.4 Reports
3.1
amt
Underwriting
Reserve Section
data Policy data

Claim_data Agent_data Client_data Reserve_data Policy_data

Payment info
Client Agent

Agent_data, Client_data, Policy_data and Reserve_data are used for validation

INSURANCE PROCESS FLOW PPT CLAIMS