Claims Investigation Process

Début du flux de travail/processus.

Fetch the initial claim entry and all associated incident reports from the Claims Data Model.

Retrieve user data and policy coverage details for the person filing the claim.

Run a formula based on incident severity, evidence strength, and policy terms to determine initial liability probability.

Create a task for the Claims Department to assign a specialized investigator to the case.

Generate a new entry in the Investigation Log data model to track all findings related to this specific claim ID.

Create a task for the investigator to gather photos, witness statements, and police reports.

Update the status field in the original Claim Entry to reflect the current stage of the process.

Fetch all uploaded files and documentation linked to the claim entry.

Aggregate all line-item repair estimates and medical bills to find the total estimated loss.

Subtract the policyholder's deductible from the total estimated loss to determine the net payable amount.

Create a task for the Fraud Unit if the calculated liability score exceeds a specific threshold.

Update the Investigation Log entry with the final conclusions and summary of the investigation.

Update the 'Final Estimated Loss' field in the Claim entry with the aggregated damage total.

Send an automated email to the policyholder informing them if the claim has been approved, denied, or requires more info.

Send an SMS to the assigned investigator when a high-priority evidence piece is uploaded.

Create a task for the Claims Manager to review and digitally sign off on the final payout amount.

Update the Claim entry status to 'Closed' or 'Settled'.

Create an entry in the Finance/Disbursement data model to trigger the actual fund transfer.

Generate a monthly performance report summarizing investigation turnaround times and loss ratios.

Delete any temporary or duplicate investigation drafts created during the process to maintain data hygiene.

Fin du flux de travail/processus.