Insurance Claims Processing Workflow

Start of the Workflow/Process.

Fetch the initial claim submission data, including policy number, claimant name, and incident date.

Retrieve data from the Customer Data Model to check coverage limits and policy status.

Apply the deductible amount to the reported loss amount to determine the initial payout liability.

Create a task for the Claims Department to assign a qualified adjuster to the new claim.

Generate a new entry in the Investigation Data Model to track findings and evidence.

Create a task for the assigned adjuster to perform a physical inspection of the damage.

Update the status field in the Claims Data Model once the adjuster is assigned.

Get all image/document entries linked to the claim incident.

Aggregate all line items from various vendor repair estimates to calculate the total estimated cost.

Run a formula comparing the claim amount against historical averages for this policy type to flag potential fraud.

Create a high-priority task for the Special Investigations Unit (SIU) if the risk score is above a threshold.

Update the 'Financial Reserve' field in the Claim Entry with the new aggregated estimate total.

Create a new entry in the Settlement Data Model containing the proposed payout breakdown.

Send an email to the policyholder explaining the settlement amount and next steps.

Create a task for the Claims Manager to review and digitally sign the settlement offer.

Update the primary Claim entry to a closed state once payment is processed.

Delete any erroneously created duplicate claim entries identified during the review process.

Generate a monthly summary report of all closed claims, total payouts, and average processing time.

Send an SMS notification to the claimant's registered mobile number confirming that funds have been released.

End of the Workflow/Process.