Claims Processing Lifecycle Management

Start of the Workflow/Process.

Fetch the primary claim entry including claimant info, incident date, and reported loss type.

Retrieve the specific policy data model associated with the claimant to check for active coverage.

Compare the reported loss amount against the maximum coverage limit defined in the policy data model.

Update the claim entry status to reflect that the initial intake is complete and investigation has begun.

Create a task for the Claims Department to assign a specific adjuster to the case.

Fetch all uploaded evidence, photos, and statements linked to the claim entry.

Create a task for the assigned adjuster to conduct field investigation or remote verification.

Create a new entry in the 'Investigation Notes' data model to document findings.

Update the claim entry with the calculated severity level based on the investigation findings.

Aggregate all line-item repair/medical costs from the 'Estimate' data model to find the total sum.

Subtract the policy deductible amount from the total loss estimate.

Update the claim entry with the final calculated net payout amount.

Create a task for the Fraud Unit if the claim severity exceeds a certain threshold.

Send an email to the claimant's email address informing them of the claim approval or denial.

Update the claim entry status to 'Closed' once the settlement is finalized.

Send an SMS to the claimant's phone number notifying them that the funds have been disbursed.

Create a summary report of all closed claims, total payouts, and average processing time for management.

Delete or flag duplicate claim entries in the system to maintain data integrity.

End of the Workflow/Process.